医疗文书包括门诊、住院病历，处方，检查、治疗申请单，报告单、会诊单、转诊单及各种护理表格等。它是医疗活动不可缺少的重要依据；是医疗、教学、科研的宝贵资料和医院管理的重要信息；也是医疗诉讼的重要法律依据。因此其质量好坏，不仅反映了医务人员的基础理论素质修养 Medical documents include clinics, inpatient medical records, prescriptions, examinations, treatment application forms, report forms, consultation forms, referral forms, and various forms of care. It is an indispensable important basis for medical activities; it is an invaluable source for medical treatment, teaching, research, and hospital management; it is also an important legal basis for medical litigation. Therefore, its quality is not only a reflection of the basic theoretical qualities of medical personnel.