What A Medical Record Should Contain

A comprehensive medical record should contain such contents:

A. The front page of a chart should includes the name, gender, age, birth date, ID number, work place, the address and telephone number of the patient's home and workplace, and what relationship between the patient and interested person (such as spouse, parents, children and so on). The diagnosis and time of the patient registered in/out of hospital and which treatment had been took. His/her family or the desk clerk may complete this page. When we need, we can get the details of the patient through such a minute record. Besides, the attending doctor should complete the medical record. Chief doctor and the doctor who is in charge of the patient should signature after reading the diagnosis.

B. The resident or intern write the brief summary, which should content the time of hospitalization, the diagnosis and so on and so forth, after the scrutinizes of the doctors in charge and the chief doctor they should make signatures respectively. To investigators, they can get what they want to get in it.

C. The notification should be make by the doctor of out-patient department, in which offered the reason why the patient have to hospitalize, what treatment will be taken, and other details. The investigators also can get information from it.

D. Case history should record by the doctor who in charge of the case, in which offered the information on the condition of the patient's health, the medical record, physical examination and others information of the case. If an intern writes it, the superior doctor should review and sign it. The patient should answer doctor's questions genuinely, but some patients fabricate some information for unknown reasons. The doctor should get the genuine information from the patient and record it in details.

E. The content of the registered record almost same to the information in the case history, and it is required written by the doctor of in charge of the case. The resident doctor and the attending doctor may be not the same one, and the interns have no authorization to make such record. F. Record about the progress of the hospitalization includes the symptom and the reason, the analysis of special examination, special treatment and the plan for the next step of treatment. If superior doctor has any advice on the treatment, he will be required sign on the relative record, which is made by the attending doctor. If the patient hospitalizes more than one month, a brief summery will be made. All of consultations, transmissions, or special operations should be written down. If an operation will be taken, minutes of discussions before the operation, records about the operation and anesthesia are all need to be provided. If the patient had dead, the attending doctor or doctor on duty must make a death certificate to attest to the death of the patient, in which should include such contents, the summary of the case history, the condition of hospitalization, the reason and the time of death, and which kind of treatment had been taken, etc. When the patient leaves hospital, the attending doctor should take a record whose content is the same as brief summary of hospital course. The attending doctor should write all the records of disease progress, the doctor on duty would make the records when the attending doctor is absent.. The doctor in charge, chief doctor or vice chief doctor make a definite diagnosis, and they should go into the wards for some time which corresponding a record. To our investigation, we can get the information about the patient's condition in hospital which includes the disease changes, mental attitude, treatment, attitude/action of the family and so on. Anything that may influences on the disease should be record and the writer should sign his/her name. During the investigation, the investigators could contact the people who are related to the case. Such record is difficult to juggle because it is based on doctors at different departments, unless the patient colludes with the hospital staff.

G. Record of consultation includes the reason for consult, the result of physical examination, the advice/suggestion for treatment and the signatures of every doctor who attended the consultation.

H. Report of X-rays.

I. Report of routine test.

J. Report of other examinations.

K. Report of special examination. A pathologic analysis report must be attached with the resected tissue.

If the check report belongs to the out-patient department, it is fetched from the lab and given to the doctor by the patient. And if it belongs to the resident department, it is delivered directly from the lab to the ward. Generally the contents of the report are genuine but sometimes the patient may give a false sample for some unmentionable reasons so that the result is false too.

L. Doctor's advice of Chinese traditional medicine.

M. If the patient is ill seriously there should be a record of special nurse in which should content the observation of vital sign, conditions of the patient and the treatment. The nurse in charge or the one who is on duty writes it.

N. Doctor's advice for a long period. It means that it will not change for some time and should be carried out timely. It includes the name, dose, direction of medicine, and time carried out. It is listed by doctor and carried out by nurse. The doctors and the nurses all should sign his/her name on it. If the doctor wants to change the advice, he should end the primary advice and list the new one and then sign on it. The nurse who will carry out the doctor's advice should also sign on it. Alter the record randomly is forbidden.

O. Doctor's temporary advice also has a sign of the doctor and the nurse and time for carrying out. It must be record clearly and should not be altered at random.

P. Temperature record bill includes the temperature, pulse per minute, blood pressure of the patient, the time of hospitalization and leaving hospital. The nurse in charge or the one on duty made it.

Q. Other relative documents.

R. Records of out-patient should include general conditions (show the date and accurate time if it is an emergency case), complaint, case history, any positive and some negative physical sign, impression and advice. If the hospitalization is needed for the patient t to be observed, the admitting doctor sign an advice note and show the reason for admitting the patient and make an impression diagnosis.
**Attention: all the papers should include the patient's name, date, registration number and sign of medical staff. There should be a case discussion and a pre discussion before a difficult operation. And there should be a mortality conference when patient is dead.

After delivered to the record room, the chart can only be lent to the doctor for case research and discussion but not allowed to modify it. Maybe it is permitted in some hospital that the doctor can borrow the record and modify it in order to improve the quality of medical record. Then it gives a chance to the person who wants to cheat on it.