随着《医疗事故处理条例》和最高人民法院《关于民事诉讼证据的若干规定》中第四条医疗过失实行举证责任倒置的司法解释的施行以及社会医疗保险制度的改革和人们法律意识的增强。病案公开后不仅对医疗工作提出了新挑战,而且对病历书写提出了新的要求[1]。为此,国家卫生部、中医 With the “Medical Accident Handling Ordinance” and the Supreme People’s Court “Regulations on Civil Litigation Evidence”, the fourth article carries out the judicial interpretation of the inversion of the burden of proof in the medical negligence and the reform of the social medical insurance system and people’s legal awareness. After the publication of the medical record, it not only poses new challenges to medical work, but also puts forward new requirements for the writing of medical records [1]. To this end, the Ministry of Health, Chinese Medicine