T/SZCHA 001-2023 Scar specialist record writing specification
T/SZCHA 001-2023 Scar specialist record writing specification
Basic Information
Scope
Scope: This document stipulates the basic requirements for the written records of scar-related diseases, as well as the admission records, progress notes, surgical records, discharge summaries, evaluation forms, and ancillary examination requirements. This document applies to medical institutions and healthcare professionals in the standardized collection, storage, exchange, and application of information on patients with scar-related diseases. Main technical content: This standard specifies the basic requirements for the written records of scar-related diseases, as well as the admission records, progress notes, surgical records, discharge summaries, evaluation forms, and ancillary examination requirements. It helps to establish a complete system of data standards and norms, facilitates the smooth work of healthcare professionals, and safeguards the legitimate rights and interests of patients.