T/SZCHA 007-2023 Stress ulcer specialist record writing and recording specification
T/SZCHA 007-2023 Stress ulcer specialist record writing and recording specification
Basic Information
Scope
Scope: This document specifies the basic requirements for the writing and recording of pressure injury-specific cases, as well as the requirements for admission records, progress notes, surgical records, discharge summaries, evaluation forms, and auxiliary examinations. This document applies to medical institutions and healthcare professionals in the standardized collection, storage, exchange, and application of information on patients with pressure injury-specific cases. Main technical content: This standard specifies the basic requirements for the writing and recording of pressure injury-specific cases, as well as the requirements for admission records, progress notes, surgical records, discharge summaries, evaluation forms, and auxiliary examinations. It helps to establish a comprehensive data standard and normative system, facilitating the smooth work of healthcare professionals and protecting the legitimate rights and interests of patients.