病历是医生对病人疾病的发生,变化、发展全过程的客观记录;是医生诊治的根据;是医务人员对该病看法、诊治法沟通思想的工具,也是科研的基本素材;在某种情况下,还具有法律上的权威性。因此对病历书写,首先要有严谨的态度,运用科学方法和井然有序、缜密的思想,采取不马虎、不 The medical record is the objective record of the whole process of doctor’s occurrence, change, and development of the patient’s disease; it is the basis for the doctor’s diagnosis and treatment; it is a tool for the medical personnel to communicate ideas through the opinion of the disease, and the diagnosis and treatment method is also the basic material for scientific research; under certain circumstances It also has legal authority. Therefore, when writing medical records, we must first adopt a rigorous attitude and adopt scientific methods and well-ordered and meticulous ideas to adopt sloppy and non-