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病案是医疗业务信息的主要来源,医疗业务中的大量信息主要贮存于病案之中,完整的病案记载有助于医、教、研、法,同时又是了解居民健康和医疗质量状况的重要资料。 病案质量的优劣与各临床科室医护人员及辅助科室有着密不可分的关系。形成病案的各个环节必须严格要求;医师对病案内容记录真实、完整、系统、科学与否,内容是否正确,项目是否齐全,字迹
Medical records are the main source of information for medical services. A large amount of information in medical services is mainly stored in medical records. A complete medical record is helpful for medical, teaching, research, and law. It is also important information for understanding the health status of residents and the quality of medical care. . The quality of the medical record is inextricably linked with the medical staff and auxiliary departments of clinical departments. All aspects of the formation of medical records must be strictly required; doctors record true, complete, systematic, and scientific contents of the medical records, whether the contents are correct, and whether the items are complete or not.