The health ministry about editing the first of cases in the notice

Health medical ZhengFa [2011] no. 84

        All provinces, autonomous regions, municipalities directly under the central government health TingJu, xinjiang production and construction corps health bureau:

        To further improve the medical institutions scientific, standardized, fineness and information management level, strengthen medical quality management and control, perfecting the medical record management, for payment reform provides technical foundation, our organization in 2001 by the experts on hospital medical record home page has been revised. Hereby printed and distributed to you, please January 1, 2012 to perform the (from the health ministry web site). The related work in time to the feedback YiZhengSi explains.

        Contact: health YiZhengSi HuRuiRong, JiaoYaHui

        Telephone: 010-68792413

        The true: 010-68792513

        E-mail: mohyzsylc@163.com

        Accessories: 1. The first of cases in hospital

                                2. The first of cases in that part of the project fill in                         

                                3. The first of cases in hospital project revised instructions

In November 2011 a day

附件1

        Attachment 2 hospital medical record home page of the project that fill in

        A, basic requirements

        (1) all of the changes made the first of cases before the first of cases with a version of the same project, not just fill in the content of the project that, still, in accordance with the health ministry issued the first of cases about editing in the notice of (health medical hair [2001] 286) the execution.

        (2) signed by corresponding part can be physicians, nurses, coders handwritten signature or use reliable electronic signature.

        (3) if the column with a "", ought to be in "" fill out appropriate in Arabic numerals. In the column of no can fill in content, fill in "". Such as: no telephone contact, in the telephone place fill out the "".

        (4) disease code: refers to the patients suffering from diseases of the standard codes. At present in accordance with the unified ICD-10 code execution.

        (5) the first of cases in part on the back for each provincial blank the administrative department of public health level based on the specific projects increase category.

        Second, notes on completing part of the project

        (1) "medical institutions" refers to the patient in the diagnosis and treatment of medical institutions in name, according to the "practice license of medical institution of the registration institution name to fill out. Organization code currently according to WS218-2002 health agency (organization) classification and code standards to fill out and code by eight ontology code, even the characters and a test of code.

        (2) medical payment divided into: 1. The town worker is basic medical insurance; 2. Urban resident basic medical insurance; 3. The new rural cooperative medical treatment; 4. The poverty relief; 5. Commercial medical insurance; 6. The public; 7. All at one's own expenses; 8. Other social insurance; 9. Other. Payment shall be according to the patient in "" fill in the corresponding in Arabic numerals. Other social insurance refers to birth insurance, inductrial injury insurance, migrant workers insurance.

        (3) health card number: has issued in unity of the People's Republic of China residents health card "of the region to fill out health card number, has not yet issued" health card "fill in the region" medical card number "patient such as identification number or ceases to fill out.

        (4) "the N time in hospital" refers to the medical institutions in patients with the number of diagnosis and treatment in hospital.

        (5) medical record number: refers to the medical institution for the patient in the medical record set the uniqueness of the code. In principle, the same patients in the same medical institutions shall use the same in many times, medical record.

        (6) age: refers to the waters with age, for patients with the calendar calculating birth calendar age. Age is full 1 one full year of life, to the corresponding integer fill in waters age; Age of less than one one full year of life, the months of age according to waters fill in, with fractional form said: scores of the integer part representative waters months, scores of the denominator for 30, the molecules for less than a month the number of days, such as "2 15/30 month" for children age 2 months for waters, and 15 days. (7) from birth to 28 days for the neonatal period. The birthday day 0. Women shall complete medical records "birth weight"; The neonatal period of children in hospital shall complete the "birth weight", "hospital neonatal weight". Birth weight children born to the first hours of the first says weight, requirement accurate to 10 grams; Admission to hospital weight newborn children said the weight, requirement accurate to 10 grams.

        (8) the place of birth: refers to the patients were born location.

        (9) native: refers to the ancestral home patients or origin.

        (10) id number: except no id number or for other special reasons not gatherers outside, hospitalized patients on admission to fill in the eighteen id number.

        (11) professional: according to the national standard "basic personal information classification and code" (GB/T2261.4) asked to fill out, altogether 13 career: 11. State public servants, 13. Professional and technical personnel, 17. Staff, 21. Enterprise management personnel, 24. Workers, 27. Farmers, 31. Students, 37. Active duty soldiers, 51. Professionals, 54. Individual operator, 70. The unemployed, 80. Retreat (from) cease personnel, 90. The other. According to the conditions of patients, fill in professional name, such as: clerk.

        (12) marriage: refers to the patients in hospital in the state of marriage. Can be divided into: 1. Unmarried; 2. Married; 3. Widowed; 4. Divorce; 9. Other. Shall, according to the state of marriage in patients with "" fill in the corresponding in Arabic numerals.

        (13) current address: refers to the patients before the recent permanent address.

        (14) registered permanent residence address: refers to the household registration in patients with address, according to the seat of registered permanent residence to fill out.

        (15) work unit and address: refers to the hospital in patients before work unit and the address.

        (16) contact "relationship" : refers to contact with patients, the relationship between the reference to the "family relations code" national standards (GB/T4761) fill in: 1. A spouse, 2. Son, 3. Female, 4. Our grandchildren or WaiSunZi, granddaughter, 5. Parents, 6. Grandparents or maternal grandparents, 7. Brother, brother, sister, a younger sister, 8/9. Other. According to the actual situation and contact with relationship fill in, such as: a grandson. For the family relations staff, unified use "other", and can add that such as: colleagues.

        (17) were admitted to the hospital way: refers to the hospital for treatment of the source of the patients treated by our outpatient and emergency, hospital, or through other medical establishment after hospital treatment referral, or the other way to the hospital.

        (18) turn coco don't: if more than more than one ZhuanKe, with "" connecting said.

        (19) in actual days: hospital discharge, only a day, calculation, for example: June 12, 2011 were admitted to the hospital, and in June, 2011, 15 of sunrise, plan days in hospital for 3 days.

        (20) the door (urgent) examine the diagnosis: refers to the patients in the hospital before, by the door (urgent) examine accepts physicians in the hospital certificate of fill in the door (urgent) examine the diagnosis.

        (21) discharge diagnosis: refers to the hospital patients, clinical doctors according to the patient do the check, treatment, and this diagnosis and surgical outcomes, such as pathological diagnosis analysis of the final diagnosis.

        1. The primary diagnosis: refers to the patients in the process of discharge from the body health hazard is the largest, most cost of medical resources, the length of time the longest disease diagnosis. The main diagnostic refers to surgical patient in the surgery to treat disease; The main diagnostic refers to maternity maternity the main complications or follow the disease.

        2. Other diagnosis: in addition to the main diagnosis and hospital infection name (diagnosis) of the other diagnoses, including the complications and complications.

        (22) were admitted to the hospital illness: refers to patients admission disease assessment. Will "discharge diagnosis" hospital compare with the disease, according to the "discharge diagnosis" in patients on admission, whether it has has, is divided into: 1.; 2. Clinical not for sure; 3. Is uncertain; 4. No. According to patients with specific circumstances, in each discharge diagnosis fill in the corresponding Arabic Numbers after.

        1. : corresponding this discharge diagnosis at admission has clearly. For example, in patients with "breast cancer" to the hospital for treatment, prior to admission has mammography, fnac diagnosis for "breast cancer", postoperative pathologic diagnosis of breast cancer by also.

        2. Clinical not for sure: corresponding this discharge diagnosis in admission clinical has not yet been determined, or admission this diagnosis for suspicious diagnosis. For example, in patients with "breast malignant tumor except not", "breast cancer?" Or "breast neoplasm" to the hospital for treatment, because it less pathology results, the mass nature has not yet been determined, discharge pathological diagnosis for breast cancer has clear or mammary gland fibroma.

        3. Is uncertain: corresponding this discharge diagnosis in the admission is uncertain. For example: the hepatitis b virus sex hepatitis window period, community-acquired pneumonia the incubation period, because the patient admission in the window period or the incubation period, it fails to consider the admission this diagnosis or failed to clear the subjective diagnosis.

        4. No: in during be in hospital new happening, admission clear no corresponding this discharge diagnosis diagnostic items. For example: patients experienced perioperative myocardial infarction.

        (23) the external cause damage, poisoning: refers to the damage to the external cause and cause of poisoning material, such as: electric shock accidents, house fire, highway car overturned, accidental pesticides. Can't fill in the car accident, trauma, general. Should fill out the damage, poisoning standard codes.

        (24) pathology diagnosis: refers to various biopsy cytology, and the diagnosis of autopsy, including intraoperative frozen pathological results. Pathological number: fill in pathological specimens Numbers.

        (25) drug allergy: refers to the patients in hospital treatment, and always in the process of doctor, clear drug allergy history, caused the allergic reaction and fill in the specific drugs, such as: penicillin.

        (26) death patients autopsy: refers to the airframe of patients on death PouYan, in order to make clear the cause of death. The death in "" the patient should fill in "" within.

        (27) blood type: refers to the hospital in during inspection clear blood type, or always medical records of patients can clear blood type. According to the actual situation of the fill in patients with corresponding Arab number: 1. A; 2. B; 3. O; 4. AB; 5. Unknown; 6. Not check. If patients without always blood type material, the hospital also not check blood type, then according to the "did not look up" to fill out. "Rh" according to patients with blood type test results to fill out.

        (28) signature.

        1. The doctor to sign can reflect level 3 doctor takes responsibility. Level 3 doctor refers to the resident, the attending physician and has more than of doctor of vice director of professional technical position qualified physicians. In hospitals, medical record in the first "of director of division" column signature can be made by responsible physician ward, such other levels of the hospital must personally signed by of director of division, if special circumstances, can be competent the designated ward responsible physician issuing.

        2. The nurse: refers to the primary nursing has the rate, responsible for the patients of holistic nursing care nurse.

        3. Coders: refers to the classification of the personnel responsible for medical record cataloguing.

        4. Control the doctor: refers to the quality of the final check medical record practitioners.

        5. Control the nurse: refers to the quality of the final check medical nurse.

        6. Qc date: quality by physicians to fill out.

        (29) surgery and operating code: at present in accordance with the unified ICD-9-CM-3 code execution. In the first line form shall complete the main surgery in hospital and the operation of the code.

        (30) operation level: refers to according to the clinical medical technology application management method "(health medical ZhengFa [2009] no. 18) requirement, build a surgery grading management system. According to the risk degree of difficulty and different, surgery is divided into four classes, fill out the corresponding operation level corresponding Arabic numerals:

        1. Level 1 surgery (code for 1) : refers to a lower risk, process simple, technical difficulties of the low average operation;

        2. Level 2 surgery (code for 2) : refers to have some risk, process complexity, have certain general technically difficult operation;

        3. Level 3 surgery (code for 3) : refers to the risk is higher, the process is more complex, difficult operation;

        4. Level 4 surgery (code for 4) : refers to the risk is high, the process is complicated and difficult to major surgery.

        (31) surgery and operating name: refers to the surgery and nonoperative operation (including the diagnosis and therapeutic operations, if intervention operation) name. In the first line form shall complete the main surgery in hospital and the operation of the name.

        (32) healing of incision level, according to fill in the following requirements:

        1.0 of incision: refers to the body's natural orifice transluminal surgery and PiQiang mirror the surgery, like the stomach laparoscopic surgery, the umbilical single-arch laparoscopic surgery, etc.

        2. "other" healing level, points out that the court did not reach the time when incision stitches come out, not take out stitches or need not take out stitches incision, healing the state has not been clearly.

        (33) anesthesia way: for patients to surgery, refers to the use of anesthesia operation methods, such as general, local anesthesia, epidural flax etc.

        (34) way of departure from the hospital: refers to the hospital patients discharged from the hospital way, fill out the corresponding Arabic numerals. Mainly includes:

        1. The doctor's advice from school (code for 1) : refers to the patients after treatment, according to request discharge from the doctor's advice, they return to further rehabilitation, etc.

        2. Upon relocating to the doctor's advice (code for 2) : refers to the medical institutions according to the need of diagnosis and treatment, patients will be transferred to the corresponding medical institutions further make a diagnosis and give treatment, for statistical "two-way referral" carrying case. If the patients receiving medical institutions clear, the need to fill in the name of the medical institution.

        3. Turn the doctor's advice community medical service/rural hospitals (code for 3) : refers to the medical institutions according to patients with diagnosis and treatment, patients will be transferred to the corresponding community health service further treatment and rehabilitation, for statistical "two-way referral" carrying case. If the receiver of patients with community medical service clear, the need to fill in the community health service organization/the new name.

        4. The doctor's advice from school (code for 4) : refers to the doctor's advice not according to patients of departure from the hospital and automatic requirements, such as: disease patients required hospitalization, but patients request discharge from the personal reasons, such discharge and not by medical personnel according to the patient's decision, belong to the doctor's advice from the court.

        5. Death (code for 5). Refers to the patients in hospital stay death.

        6. Other (code for 9) : refers to the above five discharge except to other than the situation.

        (35) if there is 31 days in hospital discharge again plan: refers to the patients in hospital after hospital discharge 31 days whether there is a need to arrange the diagnosis and treatment in hospital. If there are plans in hospital, the need to fill out the purpose, such as: a second surgery.

        (36) patients with craniocerebral injury coma time: refers to the patients with craniocerebral injury the coma time together, according to prior to admission, respectively after admission statistics, pulsation of each time to fill in a coma coma combined. Only the head injury patients need to fill in a coma time.

        (37) hospital expenses: refers to the total cost of the patient in the diagnosis and treatment during the and all the costs, all that can be made of the hospital information system to provide the charge of be in hospital of the list, hospital medical record in the first of don't fill out. Already realize town worker, urban resident basic medical insurance or new farming and instant "quote area, shall fill in" pays amount ".

        Hospital expenses including the following 10 expense type:

        1. Comprehensive medical service classes: the common use medical service department is the cost of the project happened.

        (1) general medical service charge: including inspecting fee, the bed, the consultation fee, nutrition counseling and other fees.

        (2) general treatment CaoZuoFei: including injection, debridement, treatment, urethral catheterization, oxygen, rescue, critical care and other fees.

        (3) fancy nurse cost: patients in hospital care costs and special level nursing fee.

        (4) other expenses: ward heating fee, ward KongDiaoFei, ambulance fees, body arrange fee, etc.

        2. Diagnosis class: for the diagnosis of medical service project happen costs

        (1) pathology ZhenDuanFei: during the patient in the pathology checks on the project cost.

        (2) laboratory ZhenDuanFei: during the patient in the laboratory test cost.

        (3) imaging ZhenDuanFei: during the patient in perspective, imaging, CT, mri examination, B ultrasonic inspection, the nuclide scanning, PET, imaging examination expenses.

        (4) clinical diagnosis project fee: clinical departments in all kinds of other for the diagnosis of check the project cost. Including the endoscopic examination, the anus dre, vision testing project cost.

        3. Treatment of:

        (1) the nonoperative treatment project fee: clinical use of noninvasive method for the treatment of expenses generated by the project. Including hyperbaric oxygen tank, blood purification, spirit treatment, clinical physical therapy, etc. Physical therapy is a clinical use clinical light, electricity, heat and so on the outside factors of physical treatment expenses generated by the project, such as the radiation therapy, radionuclide therapy, focused ultrasound treatment expenses generated by the project.

        (2) the surgical treatment: clinical use and the means for treatment expenses generated by the project. Including fees and all kinds of intervention, anesthesia in pregnancy and surgery, and other fees.

        4. Recover kind: the patients rehabilitation produce cost. Including rehabilitation evaluation and treatment.

        5. Of traditional Chinese medicine, Chinese medicine treatment by means of the expenditure.

        6. The western medicine class: including organic chemicals, inorganic chemical and biological products cost.

        (1) XiYaoFei: use it during the patient in the costs of western medicine.

        (2) antimicrobial drug cost: the patient in the use of antibacterial drugs during the costs of, contained in "XiYaoFei".

        7. Of traditional Chinese medicine, including proprietary Chinese medicines and herbs costs.

        (1) where expenses for medicine: use it during the patient in the costs of traditional Chinese medicine. Traditional Chinese medicine is a Chinese herbal medicine as raw materials, the preparation processing made into different kinds of traditional Chinese medicine products form.

        (2) the Chinese herbal medicine fee: use it during the patient in the costs of Chinese herbal medicine. Chinese herbal medicine mainly by the plant medicine (roots, stems, leaves, fruit), animal medicine (viscera, skin, bone, organ, etc) and mineral composition medicine.

        8. Blood and blood products categories:

        (1) blood fee: use it during the patient in the costs of blood for clinical use, including the whole blood infusion, the red blood cells, platelets, white, the cost of the plasma. Medical institutions, the clinical blood use of the charges including price, with the blood supply of blood ChuXie fees and charges.

        (2) albumin kind goods fee: patients use the cost of albumin in hospital.

        (3) globulin kind goods fee: during the patient in the use the cost of immunoglobulin.

        (4) blood coagulation for a subclass products fee: during the patient in the use of blood coagulation factor costs.

        (5) cells for a subclass products fee: during the patient in the use of cell factors expenses.

        9. Consumables class: the local health, let alone the price administration department charge consumables. According to the medical service project that category of disposable medical consumable classification. "Diagnosis of" operation used in the project are classified as consumable "check with the disposable medical cost of raw materials"; In addition to "surgical treatment" of the other treatment and rehabilitation project (including "nonoperative treatment", "clinical physical therapy" and "recovery", "Chinese medicine treatment") used in consumable all include "with the disposable medical treatment cost of"; "Surgical treatment" operation used in the project are consumables in "operation with the disposable medical cost of raw materials".

        (1) check with the disposable medical cost of raw materials: patients during be in hospital inspection institute of use disposable medical material cost.

        (2) with the disposable medical treatment cost of raw materials: patients during be in hospital treatment by use of the disposable medical material cost.

        (3) surgery with the disposable medical cost of raw materials: patients during be in hospital to surgery, intervention operation to use when the disposable medical material cost.

        10. Other categories:

        Other fee: during the patient in the above the cost of of all kinds to as combined.

        Appendix 3

        The first of cases in hospital project revised instructions

        A, "hospital" name revised as "medical institutions" name, and increased "organization code" project.

        Second, a "medical payment" revised for "medical payment".

        Three, increase the "health card number", "birth weight", "hospital neonatal weight". Added "current address" and "phone", "zip code", convenient to patients were followed up for and statistical information such as patients source.

        Four, increase the "admission way".

        Five, "room" revised for "ward".

        Six, increase the door (urgent) examine diagnosis "disease coding".

        Seven, delete the "admission condition", "hospital diagnosis", "confirmed after admission date".

        Eight, adjust the discharge diagnosis "form, make full use of limited edition, increase" other diagnosis "fill in space; Delete the form of "discharge" column, the revision for "admission illness" relevant projects; "ICD-10" revised for "disease coding".

        Nine, increases the damage, poisoning "disease coding".

        Ten, delete "hospital infection name".

        11, increases the pathological diagnosis "fill in space, increase the" disease code ", "pathological number" project. Medical institutions can, according to the medical practice, appropriately increase "tumor morphological coding" project.

        Twelve, "drug allergy" added "with and without a" option.

        13, delete "HBsAg", "HCV-Ab", "HIV-Ab".

        14, will "autopsy" revised for "death patients autopsy", and advance to the first page.

        15, will "type", "Rh" project to adjust the first page, and to fill out the contents modified.

        16, will be "the Lord (deputy Lord) let doctors" revised for "director (deputy director) physicians," delete "graduate students intern" signature item.

        17 and added "nurse" project, in order to adapt to the responsibility system of nursing service demonstration project needs.

        18, and related to the operation of the project has been revised, and in the order on the adjustment, "operation, operation" are revised for "operation and operation"; Added "operation level" project; To "healing of incision level" has been adjusted.

        19, increases the way of departure from the hospital "of the project.

        Twenty, added, "are 31 days in hospital discharge again plan".

        The 21, increases the patients with craniocerebral injury coma time "statistical projects.

        22 and delete "operation and treatment, the inspection, the diagnosis for the first case", "follow-up," "follow-up period", "demonstration teaching cases", "blood transfusions reaction", "blood transfusions variety" project.

        23, to charge of be in hospital statistics project has been adjusted, uniform standard, facilitate statistical analysis.