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病历档案是关于临床医学科学的档案资料,它完整地记录了病人历次的检查、治疗和转归的全过程,以及与疾病有关的所有问题。病历档案是医务人员给病人进行诊断和治疗的记录,是病人就医期间身体和心理情况的真实反映,是医院临床。教学、研究工作的宝贵资料,是人们向疾病作斗争的原始文献。从一定意义上讲它也是临床医学的法定文件。 但当前从病历档案的全过程管理和自身的管理相对于临床医学发展和要求,以及传统病历档案管理转变为现代病历档案信息管理的发展趋势来衡量,任务还十分艰巨。 一、病历档案的发展历史源远流长 医学是劳动人民在长期的生活及生产实践中,在与疾病作斗争的漫长过程中逐渐发展起来的。人类有文字不过有五、六千年历史,但在有文字记录以前,古人类就把医疗实践活动记录在化石、石刻、壁画上了。
The medical record file is the archive of clinical medical science. It records the entire process of the patient’s previous examinations, treatment, and outcomes, as well as all problems related to the disease. The medical records are records of the diagnosis and treatment given by the medical personnel to the patients. They are the true reflections of the physical and psychological conditions during the patient’s medical treatment and are clinical in the hospital. The precious materials of teaching and research work are the original documents that people fight against diseases. In a sense, it is also a statutory document for clinical medicine. However, the current task from the whole process management of medical record files and its own management to clinical medical development and requirements, as well as the transformation of traditional medical records management to the development trend of modern medical record information management, is still very arduous. First, the history of the development of medical records has a long history Medical is the working people in the long-term life and production practices, in the long process of fighting against the disease gradually developed. Humanity has only five or six thousand years of history, but before the records were written, ancient humans recorded medical practices on fossils, stone carvings, and murals.