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Medical records (case history) is the medical staff to patients with disease occurrence, development, prognosis, medical record active process of examination, diagnosis and treatment. Data is also collected to be induction, consolidation, comprehensive analysis, according to the prescribed format and requirements for written medical health records of patients. To summarize the clinical case history is both practical work, but also to explore the disease law and the legal basis for dealing with medical disputes, it is a national treasure. Medical records have an important role in health care, prevention, education, research, hospital management.
"Basic norms of medical records" (Methodist Medical Administration issued (2010] No. 11) Article clearly stipulates: "medical text refers to the sum of medical personnel in the form of medical procedure activities, symbols, graphics, video, and other data slices, It includes a door (emergency) medical diagnosis and medical records. "
Consolidate, the definition of medical records can be summarized as follows:
① patients about disease occurrence, development, diagnosis, treatment system records the situation;
② medical activity after induction process, analyze, organize, and format requirements and the sum of the data files written in accordance with the provisions of;
③ The data records are not in the process, such as some temporary files (such as typical: admission notes, laboratory examinations requisition records belonging to a single report, but biopsy, X-ray and the like are not, and will not classified medical record preservation);
④ medical records in case management staff after finishing archived medical records room, medical records will be transformed into medical records;
⑤ have legal effect.
General items: name, sex, age, marital status, nationality, occupation, place of birth, current address, employer, ID number, zip code, telephone, hospitalization time, recording time, a history of the narrator (specify reliability). Fill requirements: (1) age should specify the "Year", infants and young children should write "month" or "day" may not write "to", "child" and "old" and so on. (2), shall state the specific occupational job categories, such as sewing, unemployed, teachers, trade union cadres, etc., can not be generally written as workers, cadres. (3), Address: rural township to be written, village, city street house number to be written; wrote factory; workshop, team, department authorities stated. (4), hospitalization time, the recording time to indicate when a fraction. (5), a history of the narrator: adult patients described by me; pediatric or unconscious person to write the name of the Ming Dynasty claimants and their relationship with patients and so on.
To summarize the clinical case history is both practical work, but also to explore the disease law and the legal basis for dealing with medical disputes, it is a national treasure. To this end, the medical staff at the time of writing medical records must be realistic, serious, scientific rigor, meticulous. Medical records have an important role in health care, prevention, education, research, hospital management.