1, the superior physician checkup record book: requirements for record checkup time, ward, bed number, patient name, gender, age, hospitalization condition, diagnosis, checkup name, title, focusing on the record of the superior physician's role in the guidance of subordinate physicians, to put forward guiding opinions.
2, difficult to discuss the record book: the diagnosis is not clear or poor treatment of difficult cases for discussion, the requirements of the record time, place, participants, host (the academic leader of the department, the title of the attending or above), the attending physician reported history, the opinions of physicians at all levels, focusing on the record of the diagnosis, the treatment of the exact views, the moderator of the summary, the record of the signature of the physician, and so on.
3, acute and critical illnesses rescue record book: the requirements of the record rescue time (specific to the minute), location, participate in the rescue of the name of all personnel, title; patient's name, gender, age, hospitalization number, diagnosis. Detailed records of disease occurrence, development, evolution of the process, the details of the rescue and measures, as well as the results of the rescue (success or failure), the recorders to sign their full names.
4, the death of the case discussion transcript: the treatment of invalid and death of hospitalized patients to be completed within a week of the death of the discussion (autopsy of the autopsy before the discussion), the requirements of the record discussion time, location, participants, host (discipline leader, attending physician or above, or the medical section of the organization), the attending physician reported history, the name of the deceased, gender, age, occupation, hospitalization number, time of death, Diagnosis of death (including Chinese medicine, Western medicine, two diagnoses), detailed records of diagnosis and treatment, deterioration of the condition through the resuscitation process and the main measures to record the cause of death analysis and lessons to be learned, the host of the summary, the recorder to sign his full name.
5, medical quality control record book: this accounted for 50% of the quality control scores, it focuses on reflecting the level of medical technology quality within the section, according to the hospital hierarchical management of the requirements of each section, the section of the medical record writing problems to analyze, find out the reasons for the next step to put forward the corrective measures, a variety of rates of statistical analysis of the unfinished indicators should be to find out the reasons for the solutions and corrective measures, can be monthly, quarterly, quarterly, and the next step to put forward the solutions. Rectification measures, can be analyzed once a month, quarter, half a year and the end of the year.
6, consultation record book: including invited in, sent to the consultation, focusing on the record of invited in the consultation, record time, patient's name, gender, age, hospitalization number, to be invited to a certain department or a hospital physician's name, title, and then will be a detailed record of the conclusion of the consultation, sent out to the consultation, record the time of the dispatch, a certain department or hospital, the name of the physician, title.
7, business learning record book: record of the hospital or departmental lectures, record time, place, lecturer, participants, content, can also be the departmental talent training program, measures and implementation of the record book.
8, error and accident record book: require records of error and accident occurred time, place, object, reason, responsible person, processing and should learn the lessons and future countermeasures.