病案是门诊或住院诊治疾病时医务人员对其症状、医技科室检查报告结果及各种治疗、护理的详细记录所建立的案卷。它是医护人员辛勤劳动得来的,是医生医学理论和实践相结合的产物。 病案来源于医疗活动实践,所以它反映疾病的本来面目,反映医护人员在观察、治疗疾病过程中的思维和 The medical record is a case file created by the medical staff when the patient is diagnosed with an out-patient or in-patient treatment, and the detailed medical and laboratory examination report results and various treatment and nursing records. It is a result of the hard work of medical staff. It is a product of the combination of medical theory and practice of doctors. The medical record is derived from the practice of medical activities, so it reflects the original features of the disease and reflects the thinking of medical staff in the process of observation and treatment of diseases.