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“再次或多次入院记录”是2002年8月卫生部、国家中医药管理局印发的病历书写基本规范中新加入的入院记录书写格式。虽然内容不多,但是在适用范围和书写要求方面存在较多问题。国内不同版本的病历书写规范对其要求有四种不同意见。作者结合本单位近二十年书写再次入院记录的经验,具体介绍医师书写时可能遇到的问题和我院书写再次人院记录的规定和理由。
“Record again or repeatedly” is the new admission record format written in the basic norms of medical records issued by the Ministry of Health and the State Administration of Traditional Chinese Medicine in August 2002. Although not much content, but in the scope of application and writing requirements there are more problems. Different versions of the domestic medical record writing norms require four different opinions. The author combines the experience of his unit writing re-admission records in the past 20 years, and specifically introduces the problems that doctors may encounter when writing and the regulations and justifications for the hospital to write records again.