To put it simply, medical records are medical documents related to patients' health, including the subjective description of patients' condition by patients themselves or others and the objective examination results of medical staff, as well as the records of patients' analysis, diagnosis and treatment process and prognosis by medical staff, as well as relevant documents with legal significance.
What kinds of medical records are there?
Medical records are divided into outpatient medical records and inpatient medical records.
(1) outpatient medical records
Outpatient medical records are medical records compiled by doctors when they accept patients in outpatient clinics; It is also divided into initial medical records, follow-up medical records and pre-hospital emergency medical records.
Although the outpatient medical record is small, it plays a great role. Every responsible doctor, no matter how busy he is at work, will carefully improve his medical records, but in hospitals, he often sees outpatient medical records discarded by patients at will. Many patients, especially those with chronic diseases, often need multiple follow-up visits; I didn't bring my medical record when I came back, and I couldn't tell when I got sick. At that time, how did the doctor treat me, what medicine I used and what tests I did. You can't tell the doctor the test results in detail. This situation will bring a lot of unnecessary trouble to patients and doctors. In addition, when medical disputes occur, medical records are legal documents and basis, which is a kind of self-protection for patients or doctors.
(2) Hospitalization medical records
When a patient passes a series of outpatient examinations and meets the hospitalization conditions, after admission, the medical staff records the patient's medical activities such as examination, diagnosis and treatment, and it is also a patient's medical health file written in accordance with the prescribed format and requirements after summarizing, sorting out, synthesizing and analyzing the patient's medical history and medical data. This is the hospital medical record.
The contents of inpatient medical records include: basic information collection on the first page of medical records, admission records, medical history confirmation sheets, first consultation records, course records, handover records, case discussion records, various informed consent forms, operation records, consultation records, discharge records, discharge diagnosis certificates, doctor's orders, etc.
After the patient leaves the hospital, the patient's medical records should be counted, uploaded, bound, reviewed, filed and put into storage.