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病案是医院记载患者健康状况和在疾病发生、发展、诊疗过程中形成的记录。目的最初的目的是基于对病人后续的医疗作为参考,帮助医师记忆,我国明代的医学家即注重对病人诊疗的记录。方法对每个就诊病人全部建立病案,并保存在医疗单位,病人就诊即时提供利用。结果临床医师了解病人以前的病情和诊疗情况,有利于对疾病的正确处理。由于病案的日益增多,积累了大量的原始诊疗记录,为医疗、教学、科研、医院管理广泛的利用,提供宝贵的信息。
A medical record is a record of the patient’s medical condition and records formed during the course of the disease’s development, diagnosis and treatment. The purpose of the initial purpose is based on the patient’s follow-up medical as a reference to help physicians to remember that the Ming Dynasty physicians in China pay attention to the patient’s diagnosis and treatment records. Methods All patients were set up for medical records, and stored in medical units, the patient immediately provide medical treatment. Results clinicians to understand the patient’s previous condition and diagnosis and treatment, is conducive to the correct treatment of the disease. Due to the increasing number of medical records, a large number of original medical records have been accumulated, providing valuable information for the extensive use of medical treatment, scientific research and hospital management.