The guiding principle of the medical record grading system is mainly based on the diagnostic criteria of patients when they are admitted to hospital, in which the severity of the disease is the main reference index, and at the same time, it also combines the complexity of the disease, the present situation, the development trend of prognosis, and even what to do.
At present, the general classification of medical records in clinical medical institutions is generally four levels:
Type A: Generally speaking, the disease is simple, the diagnosis is clear and the development of the disease is stable. In the process of visible diagnosis and treatment, there is generally no emergency, which basically belongs to ordinary inpatients;
Type B: The condition is relatively simple, but slightly more complicated than that of Type A. Moreover, the condition is urgent and requires urgent treatment. But even so, the patient's vital signs are relatively stable, and the prognosis is relatively certain and good. Such medical records do not belong to difficult and critical inpatients;
Type C: Patients with such medical records are generally more complicated. As far as the diagnosis results are concerned, it may temporarily belong to the situation without specific diagnosis opinions, that is to say, the diagnosis is unknown, or even if there is a clear diagnosis result, it is a difficult case in which rabbits are difficult to treat, or have serious complications and poor prognosis;
Type d: this is one of the highest levels in the four-level medical record. This kind of medical records generally belong to critical and complicated patients. These patients may have unstable vital signs or failure of important organs, and most of them need immediate emergency treatment. Their future diagnosis and treatment process may be more difficult, which requires careful observation and key attention of medical staff. And most of them are cases with poor prognosis or extremely poor prognosis.
In a word, the medical record classification system allows medical staff to manage patients simply and intuitively, which helps medical staff to focus on those cases that need urgent treatment and avoid negligence.