论文部分内容阅读
门诊病案是病人在门诊、急诊就诊时医疗工作的全面记录。它客观、全面、完整、连续地记录了病人的病情变化及诊疗经过,是临床进行科学诊断治疗的基础资料。 门诊病案集中保管,使医生能够及时得到病人以
The outpatient medical record is a comprehensive record of the patient’s medical work during out-patient and emergency visits. It is an objective, comprehensive, complete and continuous record of the patient’s condition changes and diagnosis and treatment. It is the basic data for clinical diagnosis and treatment. Outpatient medical records are kept in a centralized manner so that doctors can get patients in time