急诊病案是急诊工作中的主要医疗文件,不仅能反映出急诊工作医疗质量水平,又是涉及法律方面的重要依据。所以,急诊病案是医院医疗文件中重要组成部分。我院自1987年成立急诊科以来,从急诊工作的实际需要出发,不断地对急诊病案进行改革,并且实行规范化管理。本文总结我科对急诊病案改革和管理的体会。 The emergency medical record is the main medical document in the emergency work. It not only reflects the quality of the emergency medical treatment work, but also is an important basis for the law. Therefore, emergency medical records are an important part of hospital medical documents. Since our hospital set up the emergency department in 1987, starting from the actual needs of emergency work, we have continuously reformed the emergency medical records and implemented standardized management. This article summarizes our experience in emergency case reform and management.