The latest nursing "three checks", "eight pairs", "two see" refers to what?

The first consultation is responsible for the system \x0d\\\x0d\ I. The physician or department that receives the patient for the first time is the first physician and the first department, and the first physician is responsible for the patient's examination, diagnosis, treatment, resuscitation, transfer to the hospital and transfer to the department, etc. The first physician is responsible for the patient's examination, diagnosis, treatment, resuscitation, transfer to the hospital and transfer to the department. \x0d\2, the first physician must ask a detailed medical history, physical examination, necessary auxiliary examination and treatment, and carefully record the medical record. Patients with a clear diagnosis should be actively treated or proposed treatment; patients whose diagnosis is not yet clear should be treated symptomatically at the same time, they should promptly ask for a consultation with a superior physician or a physician from the relevant department. \x0d\3, the first physician before the end of the shift, the patient should be handed over to the physician on duty, the patient's condition and matters requiring attention to be clear, and carefully make a good record of the shift handover. \x0d\\4, for emergency, critical, serious patients, the first physician should take active measures responsible for the implementation of resuscitation. If it is a non-affiliated professional diseases or multidisciplinary diseases, should organize the relevant departments to consult or report to the hospital authorities to organize a consultation. Critically ill patients in need of examination, hospitalization or transfer, the first physician should accompany or arrange for medical personnel to accompany the escort; such as the receiving hospital conditions, need to be transferred to the hospital, the first physician should be contacted with the transfer of hospitals to make arrangements for the transfer of hospitals. \x0d\\5, the first physician in dealing with patients, especially emergency, critical and serious patients, have the organization of the relevant personnel consultation, decide the patient admitted to the department and other medical acts of the right to decide, any department, any individual shall not be for any reason to shirk or refuse. \x0d\\\\\x0d\\three-tier physician check-in system\x0d\\\x0d\I. Medical institutions should establish a three-tier physician treatment system, and implement a three-tier physician check-in system for the chief physician (or deputy chief physician), attending physician and resident. \x0d\\2, chief physician (deputy chief physician) or attending physician room visits, should be attended by residents and related personnel. The chief physician (deputy chief physician) room check twice a week; attending physician room check once a day. Residents are responsible for the patients under their charge 24 hours a day, and implement morning and evening room checks. \x0d\third, for acute and critical patients, residents should always observe the changes in the condition and deal with them in a timely manner, and if necessary, they can ask the attending physician, the chief physician (deputy chief physician) to check the patient temporarily. \x0d\4, for newly admitted patients, the resident should check on the patient within 8 hours of admission, the attending physician should check on the patient within 48 hours and give advice on treatment, and the chief physician (deputy chief physician) should check on the patient within 72 hours and give guidance on the patient's diagnosis, treatment, and handling. \x0d\5, before the room check should be fully prepared, such as medical records, X-rays, all relevant examination reports and the required examination equipment. When checking the room, the resident should report the summary of the medical record, the current condition, the results of the examination and laboratory tests and put forward the problems that need to be solved. The supervising physician may do the necessary examination according to the situation, put forward the diagnosis and treatment opinions, and make clear instructions. Diet; take the initiative to seek patients' opinions on medical treatment and diet. \x0d\2, attending physician room visits, requiring a systematic check-up of patients under their care. In particular, they should focus on checking and discussing newly admitted patients, patients with acute and critical conditions, patients with unspecified diagnosis and patients with poor therapeutic effects; listening to the opinions of residents and nurses; listening to patients' statements; checking the medical records; understanding the changes in patients' conditions and soliciting their opinions on medical treatment, nursing care, diet, etc.; and verifying the implementation of medical prescriptions and therapeutic effects. \x0d\3, the chief physician (deputy chief physician) room visits, to solve difficult cases and problems; review the diagnosis of new admissions, critically ill patients, diagnosis and treatment plans; decide on major surgery and special tests and treatments; randomly check the medical prescriptions, medical records, quality of medical care, nursing care; listen to the opinions of physicians and nurses on diagnosis and treatment and nursing care; carry out the necessary teaching; and decide on the discharge of the patient, transfer to another hospital, and so on. \x0d\\\\\x0d\\\\category: Difficult Cases Discussion System \x0d\\\\x0d\\c\y/ I. Consultation and discussion should be organized for all difficult cases, those not clearly diagnosed within three days of admission, those with poor therapeutic effects, and those in serious condition. \x0d\\2, consultation by the department head or chief physician (deputy chief physician) presided over, convened the relevant personnel to participate in serious discussions, as early as possible to clarify the diagnosis, put forward treatment programs. \x0d\\3, the physician in charge must be prepared in advance, the relevant materials will be well organized, write a summary of the medical record, ready to speak. \x0d\4, the physician in charge should make a written record, and the results of the discussion will be recorded in the difficult case discussion record book. The record includes: the date of discussion, the host and the professional and technical positions of the participants, the report of the condition and the purpose of the discussion, the statements of the participants, the opinions of the discussion, etc., and the definitive or conclusive opinions are recorded in the record of the course of the disease. \x0d\\\\\x0d\\\consultation system\x0d\\\\x0d\ I. Medical consultation includes: emergency consultation, intra-departmental consultation, inter-departmental consultation, hospital-wide consultation, and out-of-hospital consultation. The consulting physician should indicate the time (specific to the minute) when signing the consultation opinion. \x0d\3, intra-departmental consultation should in principle be held once a week, with the participation of the entire department. Mainly for the Department of difficult cases, critical cases, surgical cases, the emergence of serious complications cases or cases with scientific research and teaching value of the consultation of the whole department. The consultation is organized and convened by the department head or chief resident. During the consultation, the physician in charge will report the medical history, diagnosis and treatment as well as the purpose of the consultation. Through extensive discussion, the diagnosis and treatment opinions are clarified, and the business level of the departmental staff is improved. \x0d\4, inter-departmental consultation: the patient's condition is beyond the scope of the specialty, need other specialties to assist in diagnosis and treatment, need to carry out inter-departmental consultation. Interdisciplinary consultation by the physician in charge of the proposed, fill out the consultation form, written consultation requirements and purposes, sent to the invited department. The invited department should send an attending physician or above for consultation within 24 hours. The supervising physician should be present during the consultation, introduce the condition and listen to the consultation opinions. The consultation record should be filled in after the consultation. \x0d\5, hospital-wide consultation: difficult and complex conditions and the need for multi-disciplinary *** with collaborators, public *** health emergencies, major medical disputes or some special patients should be hospital-wide consultation. Hospital-wide consultation is proposed by the director of the department, reported to the Medical Affairs (Services) Division agreed to or by the Medical Affairs (Services) Division to designate and decide the date of the consultation. The consultation department shall report in advance the summary of the condition of the consultation case, the purpose of the consultation and the personnel to be invited to the Medical Affairs Section, which shall notify the relevant departments to attend. Consultation by the medical administration (services) section or the director of the department applying for consultation hosted by the vice president of business and medical administration (services) section chief in principle should participate in and summarize the summary, should strive to unify and clarify the diagnosis and treatment of the views. The physician in charge of the consultation records carefully, and will be summarized in the consultation opinion of the medical record. \x0d\\ medical institutions should be selective hospital-wide death cases, disputes, such as cases of academic, retrospective, learning from the summary analysis and discussion, in principle, held ≥ 2 times a year, presided over by the medical administration (services) section, the participants are members of the hospital's quality of care control and management committee and the relevant departments. \x0d\6, out-of-hospital consultation. Inviting physicians from outside hospitals for consultation or sending our physicians to outside hospitals for consultation shall be carried out in accordance with the relevant provisions of the Ministry of Health's Interim Provisions on the Management of Physicians' Outside Consultations (Decree No. 42 of the Ministry of Health). \x0d\\2, critical patients should be actively rescued, normal working hours by the patient in charge of the third-level physician medical team responsible for non-normal working hours or special circumstances (such as the physician in charge of surgery, outpatient duty or leave, etc.) by the physician on duty, the major rescue event should be the head of the Department of Medicine, Medical Administration (Affairs) Section or hospital leadership to participate in the organization. \x0d\3, the physician in charge should be based on the patient's condition of timely communication with the patient's family (or entourage), verbal (during the resuscitation) or written notice of the critical illness and sign. \x0d\\4, in the resuscitation of critical illness, must strictly implement the resuscitation procedures and plans to ensure that the resuscitation work is timely, rapid, accurate and error-free. Medical personnel should work closely together, verbal medical advice requires accuracy and clarity, nurses must be repeated in the implementation of verbal medical advice. In the process of resuscitation should be made to record while resuscitation, record time should be specific to the minute. Failure to record in time, the relevant medical personnel should be in the end of the rescue within six hours to make up the record, and to explain. \x0d\V. Resuscitation rooms should be well organized, well-equipped and well-performing. First aid supplies must be implemented "five", namely, a fixed number, a fixed location, a fixed personnel management, regular disinfection and sterilization, regular inspection and maintenance. \x0d\\\\x0d\\ Surgical grading management system \x0d\\\x0d\ implementation of the "Henan Province, three-tier hospitals surgical grading management norms (for trial implementation)" (Yu Wei Medical [2005] No. 118), the second level of hospitals with reference to the implementation. \x0d\ I. Surgical classification \x0d\\ According to the complexity of the surgical process and the requirements of surgical technology, surgery is divided into four categories: \x0d\ 1, four types of surgery: simple surgical procedures, surgical technology is less difficult to ordinary common minor surgery. \x0d\2, three types of surgery: the surgical process is not complex, the surgical technology is not difficult to a variety of moderate surgery; \x0d\3, two types of surgery: the surgical process is more complex, the surgical technology has a certain degree of difficulty in a variety of major surgery; \x0d\4, one type of surgery: the complexity of the surgical process, the surgical technology is very difficult in a variety of surgeries. \x0d\2, Classification of operating physicians \x0d\2 All operating physicians should be qualified as licensed physicians in accordance with the law, and the place of practice is in the Hospital. The grading of the operating physicians is stipulated according to the health technology qualifications they have obtained and their corresponding employed positions. \x0d\1, Residents\x0d\2, Attending Physicians\x0d\3, Associate Physicians: (1) Lower seniority Associate Physicians: within 3 years of serving as an Associate Physician. (2) Higher seniority deputy chief physician: more than 3 years as deputy chief physician. \x0d\4, Chief Physician\x0d\3, Scope of Surgery for Physicians at All Levels \x0d\1, Residents: under the guidance of the supervising physician, to progressively carry out and become proficient in four types of surgery. \x0d\2, attending physicians: proficiency in three and four types of surgery, and under the guidance of higher-level physicians, gradually carry out two types of surgery. \x0d\3, low seniority associate physicians: proficiency in two, three and four types of surgery, and under the guidance of the participation of higher-level physicians, gradually carry out the first type of surgery. \x0d\4, senior associate chief physician: skilled in two, three, four types of surgery, under the guidance of the chief physician, to carry out a class of surgery. Can also be based on the actual situation alone to complete part of a class of surgery, to carry out new surgeries. \x0d\5, chief physician: skillful completion of all types of surgery, especially to complete the development of new surgery or the introduction of new surgery, or major exploratory research projects surgery. \x0d\4, surgery approval authority \x0d\1, normal surgery: in principle, by the department pre-operative discussion, by the head of the department or the head of the department authorized by the deputy director of the department for approval. \x0d\2, special surgery: any one of the following can be regarded as a special surgery, subject to serious pre-operative discussion by the department, signed by the head of the department, reported to the medical administration (business) section for the record, if necessary, by the hospital consultation or reported to the competent hospital leadership for approval. However, in an emergency or emergency situation, in order to save the patient's life, the physician in charge should make a decision on the spot, fight for time and seconds, and actively resuscitate the patient, and report to the supervising physician and the general duty in a timely manner, so as not to delay the time of resuscitation. \x0d\(1) Surgery that may lead to disfigurement or disability; \x0d\(2) Surgery that needs to be performed again on the same patient due to complications; \x0d\(3) High-risk surgery; \x0d\(4) Surgery that is new to the unit; \x0d\(5) Surgery on an unattached patient, surgery that may give rise to, or be involved in, judicial disputes; \x0d\(6) Surgery on a foreign guest, an overseas Chinese, a compatriot from Hong Kong, Macao, Taiwan, a special person, etc.; \x0d\(7) Surgery on a foreigner, an overseas Chinese, a compatriot from Hong Kong, Macao, Taiwan, etc.; and \x0d\\(7) foreign physicians who come to the hospital to participate in the operation, foreign medical practice must be in accordance with the "People's Republic of China *** and the State Practitioners Law" relevant provisions of the relevant procedures. \x0d\\\\\\x0d\\\\pre-operative discussion system \x0d\\\\x0d\ I. Pre-operative discussions must be held for major, difficult, disabling, vital organ removal and new surgeries. \x0d\3, the discussion includes: diagnosis and its basis; surgical indications; surgical methods, points and precautions; possible dangers, accidents, complications and their preventive measures of the operation; whether to fulfill the procedures of signing the surgical consent form (need to be signed by the competent physician in charge of conversation in the hospital); the choice of anesthesia, the requirements of cooperation in the operating room; postoperative precautions, the patient's ideological situation and requirements, etc.; checking the The completion of preoperative preparations. The discussion is recorded in the medical record. \x0d\4, for difficult, complex, major surgery, the complexity of the condition requires the cooperation of the relevant departments, should be invited to the Department of Anesthesiology and the relevant departments 2-3 days in advance of the consultation, and to make adequate preoperative preparations. \x0d\\3, death case discussion by the physician in charge of the report on the condition, diagnosis and treatment and rescue experience, preliminary analysis of the cause of death and death preliminary diagnosis. Death discussion includes diagnosis, treatment experience, cause of death, death diagnosis and lessons learned. \x0d\\4, the discussion record should be recorded in detail in the death discussion special record book, including the date of discussion, the moderator and the names of participants, professional and technical positions, the discussion of opinions, and the formation of a unanimous summary of concluding observations in the medical record. \x0d\2, the implementation of medical advice should be "three checks and seven pairs": before, during and after the operation; bed number, name, name of the drug, dosage, time, usage, concentration. \x0d\3, when counting medicines and before using them, check the quality, labeling, expiration date and batch number, if they do not meet the requirements, they should not be used. \x0d\4, before giving drugs, pay attention to ask whether there is a history of allergy; the use of drastic, poisonous, anesthetic and limited drugs should be checked repeatedly; intravenous drug administration should pay attention to whether there is any deterioration, whether there is any loosening or cracking of the bottle; when giving multiple drugs, pay attention to the contraindications of compounding. \x0d\5, blood transfusion should be strictly three check eight system (see nursing core system - six, check system) to ensure the safety of blood transfusion. \x0d\2, operating room \x0d\1, pick up the patient, to check the department, bed number, name, age, hospitalization number, gender, diagnosis, name of surgery and surgical site (left, right). \x0d\2, before surgery, must check the name, diagnosis, surgical site, blood dispensing report, preoperative medication, drug allergy test results, anesthesia methods and anesthesia medication. \x0d\3, where body cavity or deep tissue surgery is performed, the number of all dressings and instruments should be counted before and after surgery and suturing. \x0d\4, specimens taken off by surgery should be checked by the traveling nurse and the surgeon before filling out the pathology test for delivery. \x0d\3, Pharmacy \x0d\1, when formulating, check the content of the prescription, drug dosage, and contraindications for compounding. \x0d\2, when issuing medicines, check whether the name, specification, dosage and usage of the medicines match with the contents of the prescription; check whether the label (medicine bag) matches with the contents of the prescription; check whether the medicines have deteriorated or exceeded the expiry date; check the name and age, and explain the usage and precautions. \x0d\4, blood bank \x0d\1, blood typing and cross-matching tests, two people working to "double check and double sign", one person working to redo once. \x0d\2, the issue of blood, with the person who took the blood * * * with the check section, ward, bed number, name, blood type, cross-matching test results, blood vial (bag) number, date of blood collection, blood type and dosage, the quality of blood. \x0d\5, Laboratory \x0d\1, when taking specimens, check the section, bed number, name, purpose of the test. \x0d\2. When collecting specimens, check the department, name, sex, union number, quantity and quality of specimens. \x0d\3, When testing, check the reagents, items, and whether the lab sheet matches the specimen. \x0d\4, after the test, check the purpose and result. \x0d\5, when issuing report, check the section and ward. \x0d\6, Pathology \x0d\1, when collecting specimens, check the unit, name, sex, union number, specimen, fixative. \x0d\2. When making sections, check the number, type of specimen, number and quality of sections. \x0d\3, when diagnosing, check the number, type of specimen, clinical diagnosis, pathological diagnosis. \x0d\4, when issuing report, check the unit. \x0d\7, Radiology \x0d\1, When examining, check the department, ward, name, age, film number, site and purpose. \x0d\2. For treatment, check the section, ward, name, site, condition, time, angle and dose. \x0d\3. When issuing reports, check the section and ward. \x0d\8. Physiotherapy and Acupuncture Department \x0d\1. When various treatments are given, check the right section, ward, name, part, type, dosage, time and skin. \x0d\2, low-frequency treatment, and check the polarity, the amount of electricity, the number of times. \x0d\3, high-frequency treatment, and check the body surface and body for metal abnormalities. \x0d\4, before acupuncture treatment, check the number and quality of needles, and when removing the needles, check the number of needles and whether there is any broken needle. \x0d\9, (ECG, EEG, ultrasound, basal metabolism, etc.) \x0d\1, when checking, check the department, bed number, name, sex, and purpose of the test. \x0d\2. For diagnosis, check the name, number, clinical diagnosis, and test result. \x0d\3, when issuing report, check the section and ward. \x0d\\ Other departments should also develop a checking system for their own work according to the above requirements. \x0d\\\\\x0d\\ Doctors' handover system \x0d\\\x0d\1, ward duty need to have a first, second and third line duty staff. The first-line duty officer is a resident who has obtained the qualification of physician, the second-line duty officer is an attending physician or deputy chief physician, and the third-line duty officer is a chief physician or deputy chief physician. Trainee physicians on duty should perform medical work under the supervision of their own physicians. \x0d\2, Wards are on 24-hour duty system. The physician on duty should take over the shift on time, listen to the briefing on the duty situation by the physician on duty, and accept the medical work assigned by the physician on duty. \x0d\3, for patients with acute, critical and serious illnesses, it is necessary to do a good job of bedside handover. The physician on duty should make clear to the physician on duty the condition of the emergency, critical and serious patients and all matters that should be dealt with, and both parties should carry out a handover of responsibility signing, and indicating the date and time. \x0d\4, the physician on duty is responsible for all temporary medical work in the ward and the handling of temporary situations of patients, and make a good record of the observation of the condition of emergency, critical and serious patients and medical measures. First-line duty personnel in the diagnosis and treatment activities encountered difficulties or questions should be promptly requested to the second-line duty physician, the second-line duty physician should be timely guidance to deal with. If the second-line physicians cannot solve the difficulties, they should ask the third-line physicians to guide them. In case of special problems that need to be handled by the supervising physician, the supervising physician must actively cooperate. In case of problems that need to be solved by the administrative leaders, they should promptly report to the hospital's General Duty or Medical Administration (Affairs) Section. \x0d\5, first and second line duty physicians must stay in the duty room at night, not to leave work without authorization, and should immediately go to the clinic when they encounter situations that need to be dealt with. If there is a need to leave the ward for emergency rescue or consultation, the nurse on duty must be informed of the direction and contact method. Third-line duty physicians may stay at home, but must leave contact information and should go immediately when they receive a request call. \x0d\VI, the duty physician can not be "double duty", such as duty and outpatient clinics, surgery, etc., except for emergency surgery, but in the ward there is an emergency treatment matters, should be prepared by the shift to deal with in a timely manner. \x0d\7, the daily morning meeting, the duty physician should be the key patient situation to the ward medical staff report, and to the physician in charge of the situation of critically ill patients and yet to be dealt with. \x0d\\\\\x0d\\\\new technology access system \x0d\\\x0d\ I. New technology should be implemented only after going through the relevant procedures in accordance with the relevant national regulations. \x0d\\2, the implementer to submit a written application, fill out the "to carry out new business, new technology application form", provide the theoretical basis and specific implementation details, results and risk prediction and countermeasures, the head of the department to review and sign the consent to report to the medical administration (business) section. \x0d\3\3, medical administration (business) section organized academic committee experts to validate, put forward the views, reported to the dean in charge of the approval before the implementation of the implementation. \x0d\\4, the implementation of new business, new technology shall sign the corresponding agreement with the patient, and shall fulfill the corresponding obligation to inform. \x0d\\V, new business, new technology implementation process by the medical administration (business) section is responsible for organizing experts to carry out stage monitoring, timely organization of consultation and academic discussions, to solve the implementation of some of the larger technical problems found in the process. Daily management is completed by the corresponding control physicians and monitoring physicians. \x0d\VI, new business, new technology to complete a certain number of cases, the department is responsible for timely summarization, and submit a summary report to the Medical Administration (Services) Section, Medical Administration (Services) Section to convene a meeting of the Academic Committee, to discuss and decide whether the new business, new technology in the clinic to fully carry out. \x0d\7, the department director should be directly involved in the development of new business, new technology, and make a good department of new business, new technology to carry out the organization and implementation of the work, pay close attention to the implementation of the new project may appear in the implementation of a variety of unforeseen circumstances, and actively and properly dealt with, and make good records. \x0d\\\\x0d\\ medical records management system \x0d\\\x0d\ I. Establishment of a sound hospital medical records quality management organization, improve the hospital's "four-tier" medical records quality control system and work regularly. \x0d\\four-level quality control system of medical records: \x0d\1, the first level of quality control team consists of the director of the department, the case committee (attending physician or above), the head of the Department of Nursing. Responsible for the quality check of medical records in the department or in the ward. \x0d\2, the second level of quality control department consists of relevant personnel from the hospital administrative functions, responsible for outpatient medical records, running medical records, archived medical records, etc., monthly spot-check assessment, and the quality of medical record writing into the medical staff comprehensive goal assessment content, quantitative management. \x0d\3, the three-tier quality control department consists of full-time quality management physicians in the hospital case room, responsible for the inspection of archived medical records. \x0d\4, the fourth level of quality control organization consists of the president or vice president of business and experienced, responsible senior title of medical, nursing, technical staff and the main business management department head. Evaluation of the quality of medical records of all departments in the hospital is conducted at least once a quarter, with special emphasis on the review of the quality of the force within the force. \x0d\2, the implementation of the Ministry of Health's "basic norms for the writing of medical records (for trial implementation)" (Wei Medical Development [2002] No. 190), "Medical Records Management Regulations for Medical Institutions" (Wei Medical Development [2002] No. 193) and the province's "Medical Documentation Standardization and Management" of the requirements, focusing on the newly assigned, the new transfer of physicians and physicians for further study of the relevant knowledge and skills training in the writing of medical records. \x0d\3 Strengthening the management and quality control of running medical records and filed cases. \x0d\1, the medical record of the first medical record, preoperative conversation, preoperative summary, surgical records, postoperative (post-partum) records, important rescue records, special invasive examination, preanesthesia conversation, pre-transfusion conversation, certificate of diagnosis of discharge, and other important record content, should be written by the hospital's physician in charge of the writing or review of the signature. Surgical records shall be written by the operator or the first assistant. If the first assistant is a physician in training, it shall be reviewed and signed by the physician of this hospital. \x0d\2. Upon admission of an ordinary patient, the physician-in-charge shall, within 8 hours, view the patient, ask for medical history, write the first record of the patient's course, and process the medical order. Emergency patients should view and deal with the patient within 5 minutes, hospitalized medical records and the first medical record should be completed within 2 hours in principle, due to the rescue of the patient failed to complete in time, the relevant medical staff should be within 6 hours after the end of the rescue according to the fact of making up the record, and be noted. \x0d\3, newly admitted patients, within 48 hours there should be attending physician above the title of physician room visit records, general patients should be 2 times a week chief physician (or deputy chief physician) room visit records, and be noted. \x0d\4, the record of the course of the critically ill patients at least 1 time a day, when the condition changes, record at any time, the record time should be specific to the minute. For seriously ill patients, record the course record at least once in 2 days. For stabilized patients, at least once every 3 days. For patients with stable chronic diseases, record the course of the disease at least once every 5 days. \x0d\5, a variety of laboratory tests, report cards, blood dispensing orders should be posted in a timely manner, and loss is strictly prohibited. Medical documents from outside hospitals, if used as the basis for diagnosis and treatment, should be entered into the medical record, while the treatment documents should be attached to the medical record of the hospital. If the imaging data or pathological data of the foreign hospital are needed to be used as the basis for diagnosis or treatment, the physicians of the relevant departments of the Hospital should be asked to consult with each other, and written consultation opinions should be written out and stored in the inpatient medical record of the Hospital. \x0d\4, discharge medical records should generally be filed within 3 days, special medical records (such as death medical records, typical teaching medical records) filed no more than 1 week, and promptly reported to the medical records office for registration. \x0d\V. Strengthen the safekeeping of medical records to prevent damage, loss, theft, etc. When photocopying medical records, they should be escorted by health care workers or re-copied by specialists in the case room. \x0d\6, based on the requirements and provisions of the "Interim Measures for Provincial Medical Records Quality Management Evaluation Rewards and Punishments", the establishment of departmental and individual medical records writing quality evaluation notification system and reward and punishment mechanism.