1, medical record information: including the patient's medical records, medical orders, test reports, surgical records, drug treatment records, nursing records, etc.. This information is the core content of the review of medical records, used to assess the quality of medical care and determine whether there is a problem.
2. Relevant medical documents: These include surgical requisitions, surgical risk assessment forms, referral cases, hospitalization summaries, and discharge instructions. These documents provide additional background information and help to understand the patient's overall care process.
3. Quality assessment tools: Healthcare organizations use a number of assessment tools to review cases, such as rating scales and assessment indicators. These tools are prepared to facilitate assessment and documentation by the assessor.
4. Review reports and records: The process and results of case review should be recorded and reported. These records include the time of reviewing the case, participants, assessment results, problems found and suggestions for improvement.