病历是经医务人员、医疗信息管理人员收集、整理、加工后形成的具有科学性、逻辑性、真实性的医疗卫生科技档案。当前,医院医、教、研、管理以及医疗保险、司法依据、患者知情等方面越来越多的依赖于病历信息。然而,以纸质病历或“打印病历”为媒介的常规病历信息获取模式已无法适应满足医院和社会对病历信息利用需求的不断深入。为此,笔者深入 Medical records are medical, scientific, logical and authentic medical and scientific files created by medical personnel and medical information management personnel after they are collected, sorted and processed. At present, more and more medical information, hospital teaching, research, management and medical insurance, judicial basis, patient information and other aspects rely on medical records. However, the conventional medical record information acquisition mode based on paper medical record or “print medical record” has not been adapted to meet the needs of hospital and society for the utilization of medical record information. To this end, the author in-depth