Medical record writing standards and case management

Author: Xu Shuzhen, Ma Haiyan
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] by the National Ministry of Health, provincial health departments, local health bureaus, and medical institutions have placed increasing emphasis on the writing of medical records and have become more explicit in their requirements for standardized record-keeping. This book is based on the relevant regulations for 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 for medical record writing from health departments in several provinces and the latest 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 writing emergency and outpatient records, inpatient records, admission records, specialty records, and progress notes for various departments. It also provides requirements and examples for related record-keeping in surgical departments, as well as writing requirements and examples for various notices, application forms, and report forms. Additionally, it covers writing requirements and examples for prescriptions, medical orders, and nursing documents. It includes requirements for various informed consent forms and medical assessment documents, specific regulations for medical case management, and methods for evaluating medical documents. The appendix reproduces relevant documents on medical record writing issued by the National Ministry of Health, common medical terms and abbreviations, clinical laboratory reference values, conversion tables for old and new units of laboratory values, English-Chinese comparison tables for common diseases in internal medicine, and Greek letters, Roman numerals, and common element tables. It is a comprehensive and richly detailed reference book on medical record writing, suitable for medical personnel at all levels in various hospitals.