病案是疾病发生、发展诊疗和转归过程的记录,是医疗、教学科研、卫生保健的信息资料,也是医疗保险、索赔、解决医疗纠纷,判定法律责任的事实依据。随着医疗制度的改革,尤其是“医疗事故处理条例”法规的实施,病案的利用率越来越大。但是,纵观 The medical record is the record of disease occurrence, development diagnosis and treatment, and outcome process. It is medical information, teaching and scientific research, and health care information. It is also a factual basis for medical insurance, claims, and resolution of medical disputes. With the reform of the medical system, especially the implementation of the “Regulations on the Treatment of Medical Accidents”, the utilization rate of medical records is increasing. However, looking at