病历档案（以下简称为“病案”）是医务工作者在医疗活动中直接形成的,它客观、完整、连续地反映出每个患者的病情变化情况和诊治过程,是医疗活动的原始记录。内容完整的病案不仅是医务人员诊治疾病的依据,也是医学研究的宝贵财富,有时甚至是执法人员办案的法律依据,随着现代医学的深入发展和病案信息种类的不断增加,病案也成为医院质量检查和各项医疗、护理、医技考核的依据,因此,病案管理成为医院管理工作中不可忽视的重要组成部分,并发展成为一门独立的学科。但就目前我国病案管理的情况看仍然没有引起足够的重视,本文想就此谈一点粗浅的认识和看法。 Medical records (hereinafter referred to as “medical records”) are formed directly by medical workers in medical activities. They objectively, completely and continuously reflect the patient’s condition and diagnosis and treatment process, and are the original records of medical activities. The complete medical record is not only the basis for the medical staff to diagnose and treat the disease, but also the valuable asset for medical research. Sometimes it is even the legal basis for the law enforcement officers to handle the case. With the further development of modern medicine and the increasing types of medical record information, Inspection and medical, nursing, medical examination basis, therefore, medical record management has become an important part of hospital management can not be ignored, and developed into an independent discipline. However, at present, the situation of medical record management in our country still does not get enough attention, this article would like to talk a little superficial understanding and opinion.