Medical record writing standards (revised version)

Author: Gao Kaiyan, Quan Xunzhen
Publisher:
Publish Date: 2006-06-01
Features: To seriously implement the spirit of a series of documents formulated by the Ministry of Health and the National Administration of Traditional Chinese Medicine, such as the "Basic Standards for Medical Record Writing (Trial)," the "Administrative Measures for Medical Institutions Medical Records," and the "Ministry of Health's Notice on Revising and Issuing the Hospital Admission Medical Record," the Provincial Health Department established an editorial committee in September 2003 and began to organize the revision of Anhui Province's 1991 edition of the "Medical Record Writing Standards." After the concerted efforts and hard work of nearly 100 clinical experts and hospital management experts in the province, and after multiple revisions over a period of 10 months, the entire revision task was finally completed. It is now officially published and released by Anhui Science and Technology Press. Medical records have long been medical and clinical documents that objectively and truthfully record the occurrence, development, and outcome of patients' diseases, reflecting the entire process and quality of medical services provided by medical institutions. Medical record writing is not only a fundamental skill that clinical medical staff must master but also an essential aspect that medical institutions cannot overlook in terms of professional practice and standardized management. Standardizing medical record writing is closely linked to the deep, systemic, and institutional development of modern hospital management.