Denomination, Format, and Content of Medical Record

Abstract

The broad inpatient medical record includes all kinds of inpatient data regarding the medical activities for the patient, while the narrow one is medical files that summarize, analyze, and sort the relevant data obtained from inquiries, physical examinations, auxiliary examinations, diagnoses, treatments, etc., mainly including complete medical record, admission record, re- or multi-admission record, admission and discharge record within 24 h, admission and death record within 24 h, general and special progress records, all kinds of informed consent forms, and critical illness notice.