How to write the medical record writing standard? How often do you record the course of the disease?

The course record is a record reflecting the evolution of the patient's condition, the process of diagnosis and treatment and other special circumstances during hospitalization.

First, the completion time of the course record

1, the first course of disease

Emergency critical patients should be completed in time, and chronic patients should be completed within 24 hours.

2. General course records

Critical patients should be recorded at any time, and patients should be recorded every day, and the specific recording time (when and how many minutes) should be indicated; Patients were recorded once every 1 ~ 3 days on average; Patients with chronic diseases, convalescence and stable condition can be recorded once every 5 days; After the operation, the patient should be recorded continuously for 3 days, and then according to the condition, according to the above requirements.

Second, the course record content

1, the first course of disease

The contents of the first visit record include: general items such as name, sex, age and occupation, main clinical symptoms and signs, laboratory examination and instrument examination, preliminary diagnosis and diagnosis basis, and preliminary diagnosis and treatment plan (including examination items, treatment and nursing measures, etc.). ). The critically ill patients should record the rescue situation, dosage, method and execution time in detail, and explain it to their families or units, and put forward the matters needing attention in observing the changes of their condition. Superior doctors should review and sign in time.

2. General course records

(1) Changes of illness, analysis of possible causes and treatment suggestions, general situation of patients' ideological trends, diet, defecation, etc.

(2) Timely and truthfully record the analysis, diagnosis and treatment opinions, case discussions and diagnosis and treatment suggestions put forward by superior doctors during rounds, which should reflect the "three-level" rounds.

(3) the implementation of the treatment plan, efficacy and response, laboratory and special inspection results and judgments.

(4) the course of disease, examination results, patient status and diagnosis and treatment of adverse reactions.

(5) Modification, supplement and basis of diagnosis and treatment plan during hospitalization.

(6) The reflections, hopes and opinions of family members and relevant personnel (if necessary, please ask family members or unit leaders to sign, and indicate the relationship with patients and the date of signing).

(7) For patients who have been hospitalized for a long time, make a stage summary regularly (1 ~ 2 months), including the stage condition and diagnosis and treatment situation, the current patient's situation and problems in diagnosis and treatment, and revise the diagnosis and treatment plan when necessary.

Requirements for writing time and times of daily course records:

1, for critically ill patients, the course of disease should be recorded at least 1 time every day according to the change of illness, and the change of illness should be recorded at any time, and the recording time should be minutes;

2. For critically ill patients with stable condition, record 1 course of disease for at least 2 days;

3. For ordinary patients with stable condition, record 1 course of disease for at least 3 days;

4. Newly admitted patients should have a course record of 3 consecutive days;

5, the day before the patient was discharged from the hospital, there should be a record of the course of the superior doctor's rounds;

6, automatic discharge patients should have a course record on the day of discharge;