T/SZCHA 003-2023 Frostbite specialist writing record specification
T/SZCHA 003-2023 Frostbite specialist writing record specification
Basic Information
Scope
Scope: This document specifies the basic requirements for the written records of frostbite special diseases, as well as the admission records, progress notes, surgical records, discharge summaries, evaluation forms, and auxiliary examination requirements. This document applies to medical institutions and healthcare professionals in the standardized collection, storage, exchange, and application of information on patients with frostbite special diseases. Main technical content: This standard specifies the basic requirements for the written records of frostbite special diseases, as well as the admission records, progress notes, surgical records, discharge summaries, evaluation forms, and auxiliary examination requirements. It helps to establish a complete data standard and normative system, facilitating the smooth work of healthcare professionals and safeguarding the legitimate rights and interests of patients.