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病案档案是医务人员记录疾病诊疗过程的文件,它记录了病人的病情变化,诊疗经过及转归情况,是临床进行科学诊断、治疗的基础材料,也是医学科学研究、临床教学的宝贵材料。随着医院管理日益科学化、现代化和标准化,病案管理已成为医院管理的重要组成部分,在医院的业务活动中,病案管理的好坏直接影响到医疗、教学、科研和医院管理工作的水平,甚至影响到医院的经营活动。因此,重视医院病案管理,科学管理与利用病历档案具有十分重要的现实意义。
Medical records are records of medical staff records of disease diagnosis and treatment process, which records the patient’s condition changes, diagnosis and treatment after the outcome of the situation, is the clinical scientific diagnosis and treatment of basic materials, but also medical science research, clinical teaching valuable material. With the increasingly scientific, modern and standardized hospital management, medical record management has become an important part of hospital management. In the business activities of the hospital, the medical record management directly affects the level of medical, teaching, scientific research and hospital management. Even affect the hospital’s business activities. Therefore, paying attention to hospital medical record management, scientific management and utilization of medical record files have very important practical significance.