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河北省医疗机构病历书写规范细则2013版

发布时间：2023-09-21 03:28:55 来源：文档文库

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河北省医疗机构病历书写规范细则（2013版）

河北友爱医院

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目录
河北省医疗机构病历书写规范细则（2013版）.....................................................2
第一章基本要求.................................................................................................................................2第二章门（急）诊病历书写内容及要求.........................................................................................7第三章急诊留观病历书写内容及要求...........................................................................................10第四章住院病历书写内容及要求...................................................................................................11第五章打印病历内容及要求.............................................................................................................52第六章病历内容及排列顺序...........................................................................................................53第七章其他.........................................................................................................................................56附表一：使用自费、贵重药品、检查和医用耗材告知同意书样表...............................................57附表二：病危病重通知书参考样表...................................................................................................58附表三：输血/血液制品治疗知情同意书格式参考格式..................................................................59附表四：授权委托书参考格式...........................................................................................................61附表五：自动出院或转院告知书参考范本.......................................................................................62附表六：急诊留观记录表格式样.......................................................................................................63附表七：急诊留观小结、留观病例首页范本...................................................................................65附表八、住院病历首页样表...............................................................................................................67附表九、产科入院记录可参照样式...................................................................................................69附表十：入院护理评估单参考样表...................................................................................................71附表十一：疼痛评估记录表（医院通用版）参考模式...................................................................72附表十二：麻醉术前访视记录单参考样表.......................................................................................73附表十三、麻醉术后访视记录单参考样表.......................................................................................74附表十四、手术安全核查表参考格式...............................................................................................75附表十五、手术风险评估表参考样式...............................................................................................76附表十六、手术护理记录单参考样表...............................................................................................77附表十七、手术患者交接护理记录参考样表...................................................................................78附表十八、护理记录单1样表...........................................................................................................79附表十九、护理记录单2样表...........................................................................................................81
河北省住院（门诊）病历质量评估标准................................................................80

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