病历档案,又称病案,是指按规范记录患者疾病表现和诊疗情况的档案,同时也是医务人员记录疾病诊疗过程的文件,由医疗机构的病案管理部门按相关规定保存。不仅有纸质的,还有电子文档、医学影像检查胶片、病理切片等保存形式。它客观地、完整地、连续的记录了患者的病情变化、诊疗 Medical record files, also known as medical records, refer to records of patients’ disease performance and diagnosis and treatment according to specifications. They are also documents for medical personnel to record the disease diagnosis and treatment process. The medical record management department of a medical institution saves according to relevant regulations. Not only paper, but also electronic documents, medical imaging inspection film, pathological sections and other forms of preservation. It records patient’s condition changes, diagnosis and treatment objectively, completely and continuously.