Medical Records - Writing Standards and Case Management

Author: Xu Shuzhen
Publisher:
Publish Date: 2007-01-01
Features: Since the promulgation of the "Medical Accident Handling Regulations" and the "Medical Records Management Provisions for Medical Institutions [（2002）193]," both the National Ministry of Health, provincial health departments, local health bureaus, and medical institutions have placed increasing emphasis on the documentation of medical records, with ever more explicit requirements for standardized record-keeping. This book is compiled in accordance with the relevant regulations on medical record writing, including the "Basic Standards for Medical Record Writing [（2002）190]," the "Basic Standards for Medical Record Writing [National Medical Record Quality Monitoring Committee, January 2003]," and the "Basic Standards for Medical Record Writing for Traditional Chinese Medicine and Integrated Traditional Chinese and Western Medicine [（2002）36]," combined with the needs of clinical medical development in recent years. It references specific regulations on medical record writing from several provinces and cities, as well as new materials. The book consists of 18 chapters (excluding the appendix) and 121 sections, covering the history, development, and role of medical records and medical case files. It includes requirements and typical examples for the writing of emergency and outpatient medical records, inpatient medical records, admission records, specialty-specific records, and progress notes. It also provides requirements and examples for related record-keeping in surgical departments, as well as the writing of various notices, application forms, and report forms. Additionally, it covers the writing requirements and examples for prescriptions, medical orders, and nursing documents. The book also outlines the writing requirements and examples for various informed consent forms and medical expert assessment documents, specific regulations for medical case management, and methods for evaluating medical documents. The appendix includes relevant documents on medical record writing issued by the National Ministry of Health, common medical terminology and abbreviations, clinical laboratory reference values, conversion tables for old and new units of measurement, an English-Chinese comparison table for common internal medicine diseases, and Greek letters, Roman numerals, and a table of common elements. It is a comprehensive and richly informative reference book on medical record writing, suitable for medical institutions at all levels and healthcare professionals of various qualifications.