病历是病人的病情档案。众所周知,完整而准确的病历是诊断疾病的钥匙,是保证病人得到正确治疗的先决条件,也是衡量医院及医生工作质量的标准之一。病历不仅对临床工作有重要影响,而且对教学、科研也具有重大意义。早在公元前二百多年,《史记》里就载有淳于意的医案。这些医案详细记录了病人姓名、地 The medical record is the patient’s condition file. As we all know, a complete and accurate medical record is the key to the diagnosis of disease. It is a prerequisite for ensuring that patients receive the correct treatment, and it is also one of the criteria for measuring the quality of work of hospitals and doctors. Medical records not only have an important impact on clinical work, but also have great significance for teaching and scientific research. As early as 200 years BC, the “Historical Records” contained a medical record of ignorance. These medical records recorded the patient’s name and place