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病案中包含着非常丰富的各类信息,长期以来病案中的各类信息在医疗、教学、科研、医院统计、医院管理、科研学术论文撰写等方面被广泛的利用,并在各个方面都做出了很大的贡献。病案信息不仅能够为医院的管理决策者提供及时、准确、详尽和可量化的参考数据,而且也是评价和衡量医疗质量,反应医疗水平和管理水平的综合依据。此外,病案还是具有法律效力的医疗文件。
The medical record contains a very rich variety of information. For a long time, various types of information in the medical record have been widely used in medical, teaching, scientific research, hospital statistics, hospital management, academic research paper writing, etc., and have been made in various aspects. A great contribution. The medical record information can not only provide timely, accurate, detailed and quantifiable reference data for the hospital’s management decision-makers, but also a comprehensive basis for evaluating and measuring the medical quality and reflecting the medical level and management level. In addition, the medical record is still a legally valid medical document.