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病历档案是医务人员记录疾病诊疗全过程的文件,它客观、真实、完整地记录了病人的病情变化、诊疗经过、用药过程及最终的治疗效果,是医疗、教学、科研的基础资料,也是医学科学的原始档案材料。病历档案不仅被医疗、教学、科研方面所使用,同时也被广泛应用于医疗保险、法律取证、医疗纠纷等方面。我们要通过病历档案管理制度标准化、管理方法现代化、病历档案管理人员知识化及病历档案质量监控专业化几个方面来提高病历档案的现代化管理水平,使病历档案信
Medical records are medical records of the entire process of disease records and files, it objectively, truly and completely records the patient’s condition changes, diagnosis and treatment, medication process and the ultimate treatment effect, is the medical, teaching, scientific research, basic information, but also medicine Scientific original archival material. Medical records files not only medical, teaching, scientific research used, but also widely used in medical insurance, legal evidence, medical disputes and so on. We must improve the modern management level of medical record files through standardization of medical record file management system, modernization of management methods, knowledge of medical record file managers and specialization of medical record file quality control so that medical record files