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病历档案简称病案,又称病历,是医务人员对病人疾病诊断治疗过程所记录的文件。病案作为临床科学诊断治疗的基础资料和医学科学的原始资料,是国家档案和科技档案的重要组成部分。实践证明,病案蕴含了的丰富的信息资源,对现代医院管理和社会建设均具有非常重要的的价值。加强病案的管理、有效开发和利用,充分发挥病案信息的价值,具有十分重要的意义。
Medical records short history of the case, also known as medical records, medical staff diagnosis and treatment of patients with the process of documenting the record. Medical records as the basis of clinical science diagnosis and treatment of medical science and the original data is an important part of the national archives and technology files. Practice has proved that medical records contain a wealth of information resources, the modern hospital management and social construction has a very important value. It is of great significance to strengthen the management of medical records, effectively develop and utilize them, and give full play to the value of medical records.