病案是有关医疗记录的案卷,是患者接受检查、诊断、治疗、护理及记录疾病发生、发展全过程的原始记录。住院病案是永久保存档案,是司法诉讼中司法鉴定的原始法律依据,具有重要的法律价值。面对病历公开化和医疗纠纷增多现状,提高医疗病案的质量已是当务之急。 The medical record is the file of the medical record and is the original record of the patient undergoing examination, diagnosis, treatment, nursing and recording the whole process of disease development and development. The inpatient medical record is a permanent record, and it is the original legal basis for judicial identification in judicial proceedings. It has important legal value. Faced with the openness of medical records and the increasing number of medical disputes, it is imperative to improve the quality of medical records.