Medical record writing standards and management regulations, as well as case (case) medical quality evaluation standards

Author: Hunan Provincial Health Department
Publisher:
Publish Date: 2004-07-01
Features: Medical records are the sum of various records created by medical staff in hospitals during medical activities, reflecting the comprehensive quality and management level of the hospital. As valuable information resources of hospitals, medical records provide a basis for clinical work, teaching, scientific research, and possess legal validity. All levels of hospitals must attach great importance to the writing of medical records and strengthen the standardized and normalized management of medical record writing. In addition to making necessary revisions to the case classification and medical defect grading standards evaluation methods in the original "Medical Record Writing Standards and Management Regulations and Case (Case) Medical Quality Evaluation Standards," this book also adds content such as medical record home page writing, formatted medical record writing for some departments, doctor-patient communication records, writing of various examination, treatment application forms and reports, medical record management, and some appendices, while removing the detailed medical quality scoring rules. The evaluation standards now include hospital infection content and remove the "Other" category. It places strong emphasis on the quality of diagnosis, treatment, and surgery, further reflecting the principles of scientificity, practicality, and operability, as well as the human-centered, compassionate service concept.