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第一章总则第一条为加强医疗机构病历管理,保障医疗质量与安全,维护医患双方的合法权益,制定本规定。第二条病历是指医务人员在医疗活动过程中形成的文字、符号、图表、影像、切片等资料的总和,包括门(急)诊病历和住院病历。病历归档以后形成病案。第三条本规定适用于各级各类医疗机构对病历的管理。第四条按照病历记录形式不同,可区分为纸质病历和电子病历。电子病历与纸质病历具有同等效力。
Chapter I General Provisions Article 1 These Provisions are formulated to strengthen medical records management in medical institutions, ensure medical quality and safety, and safeguard the legitimate rights and interests of both doctors and patients. Article 2 Medical records refer to the sum of words, symbols, charts, images, slices and other information formed by medical staff during the course of medical activities, including the emergency medical records and hospital records. Medical records after the formation of medical records. Article 3 These Provisions apply to the management of medical records of all kinds of medical institutions at all levels. Article 4 In accordance with the different forms of medical records, paper medical records and electronic medical records can be distinguished. Electronic medical records and paper medical records have the same effect.