General office of the national health and family planning commission concerning the obstetric table records template of notice

The 2016-06-15 national health and population and family planning commission of the People's Republic of China

Countries who do medical letter [2016] no. 604

Provinces, autonomous regions and municipalities directly under the central government health and family planning commission, the xinjiang production and construction corps health bureau:

To simplify the obstetric medical documents, by organization established obstetric table, medical record templates. Hereby printed and distributed to you (can be in the national health and family planning commission website "medical administration medical tube" download), use for reference, and put forward the following requirements:

One, the application of obstetric table records issued by the medical institution shall be by commission of the obstetric table, medical record templates to refine, perfect, formulated in accordance with our actual medical record templates, and actively create conditions to promote the implementation. Conditional medical institutions, related templates can be incorporated in the electronic medical record system.

Second, the medical institutions obstetric medical personnel records normal childbirth puerpera related medical record information, you can use the obstetric table records. Abnormal childbirth and pregnancy complications and other complications such as special cases, other diagnosis and treatment, to record relevant medical records in accordance with relevant regulations, shall not use medical record form.

Three, medical institutions should strengthen the management of medical record quality, on the premise of guarantee medical quality and medical safety, standardize the obstetric table of the utilization of medical records. Obstetric table of the utilization of medical records of the medical staff shall be completed medical institutions stipulated number of complete medical records.

Four, obstetric table records record, use, preservation and management, etc., in accordance with the regulations on the medical record management of medical institutions (2013 edition) ", "the medical record writing basic norms" and "basic rules electronic medical records (try out)" and so on.

Attachment: obstetric table records template. Docx

General office of national health and family planning commission

On June 6, 2016