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病案是记录病人的入院及诊治过程、病情的发展、演变、转归过程的再现[1]。随着医疗改革的深入,增加了病案的公开性与透明度。病案管理不再是以往单一的收集、整理、装订、编目、保管,由单一的封闭保管型向开放型转变。首先它的使用对象不再仅局限于院内的科研教学、职称评定、
The record is the record of the patient’s admission and diagnosis and treatment process, the development of the disease, evolution, the reproduction of the outcome of the process [1]. With the deepening of medical reform, medical records have increased the openness and transparency of medical records. Medical records management is no longer a single collection, sorting, binding, cataloging, custody, from a single closed-type custody to open change. First of all, its object of use is no longer limited to the hospital’s scientific research teaching, job evaluation,