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病案,是病人的医疗档案。是医院医疗工作负有一定法律意义的文件,也是医院的宝贵财富和珍贵的科研资料宝库。每份病案都凝集着各级医务人员的辛勤劳动,它客观如实地记载了病人疾病的发生、发展、诊断、治疗以及住院期间整个医疗活动的全部过程。通过病案可以直观地反映医院的诊疗技术、仪器设备、人员素质、管理服务和后勤保障的综合水平。一份好的病案,
The medical record is the patient’s medical file. It is a document with certain legal significance for hospital medical work. It is also a valuable treasure of the hospital and valuable treasure of scientific research materials. Each medical case agglomerates the hard work of medical personnel at all levels. It objectively and faithfully records the entire process of the patient’s disease occurrence, development, diagnosis, treatment, and the entire medical treatment during hospitalization. The medical record can intuitively reflect the comprehensive level of the hospital’s diagnosis and treatment technology, equipment, personnel quality, management services and logistics support. A good medical record,