病案,是门诊或住院诊断治疗疾病时,医务人员将其症状、体征、实验室检查结果及各种治疗的详细记录建立的案卷。这种关于病案的案卷,称为病案。它可使医疗、教学、科研工作获得丰富、可靠和有价值的资料。 病案,是珍贵的医学科研资料,它是反映疾病的本来面目,反映医护人员在观察、治疗疾病过程中的思维和行动,它是进行医学科学研究,充实医学教材,提高医疗质量的可靠资料,大体上可以写成这样一个公式,即:医疗→病案→科研→医疗。这里后一个医疗绝不是简单的重复前一个医疗,它是从医过程中产生的病案,经过分析、研究、总结出在医疗实践中成功的经验和失败的教训,提高了医疗技术再用于医疗,这个医疗就会 The medical record is the case file of the medical staff’s detailed records of their symptoms, signs, laboratory test results, and various treatments when they are diagnosed or treated by an outpatient or inpatient. This kind of case file is called a medical record. It can make medical, teaching, scientific research work rich, reliable and valuable information. Medical records are precious medical scientific research materials. They reflect the true features of diseases and reflect the thinking and actions of medical personnel in observing and treating diseases. They are reliable data for carrying out medical scientific research, enriching medical teaching materials, and improving the quality of medical treatment. It can be roughly written as a formula: medical → medical record → scientific research → medical treatment. Here the latter medical treatment is by no means a simple repetition of the previous medical treatment. It is a medical record generated from the medical process. After analysis, research, and summing up successful experiences in medical practice and lessons learned from failure, medical technology has been re-used for medical treatment. This medical treatment will