Chinese Medicine Medical Record Standardized Writing Manual

Author: Wang Yongyan, Editor-in-Chief
Publisher:
Publish Date: 2005-01-01
Features: This manual mainly includes 3 projects: [Regulatory Requirements] Original excerpts from the "Basic Norms for Writing TCM and Integrated Traditional Chinese and Western Medicine Medical Records (Trial)" regarding the content, format, and writing requirements of medical records; [Examples] Demonstrates the specific application of [Regulatory Requirements] through writing examples; [Remarks] This section provides further explanations and notes on the concise original text of the "Basic Norms for Writing TCM and Integrated Traditional Chinese and Western Medicine Medical Records (Trial)," as well as relevant precautions, for reference only and not binding. For the parts of the "Basic Norms for Writing TCM and Integrated Traditional Chinese and Western Medicine Medical Records (Trial)" that do not have unified format requirements, the parts specifically handled by the nursing department or administrative department, as well as various materials related to the writing of TCM and integrated traditional Chinese and Western medicine medical records, such as the "List of TCM and Western Medicine Syndromes and Treatment Methods," the "Comparison Table of TCM and Western Medicine Disease Names in Common Diseases," and the "List of Common Standard Medical and Medicinal Terms," are included as appendices for reference when readers study and implement the "Basic Norms for Writing TCM and Integrated Traditional Chinese and Western Medicine Medical Records (Trial)." With the widespread use of computers, medical records in some large hospitals abroad and in China have adopted the 24-hour system. The [Examples] in this book also recommend this more scientific timekeeping method, and readers may choose accordingly. This book is closely aligned with the new "Basic Norms for Writing TCM and Integrated Traditional Chinese and Western Medicine Medical Records (Trial)" and has strong practicality and operability, making it convenient for clinical physicians to use as a reference at their desks.