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病案是病人的医疗档案,它全面真实地记录了患者疾病发生发展的全过程,记录了医务人员诊治病人过程的全部思维和行动。它是医务人员开展医疗活动的原始记录,具有重要的医学参考利用价值,是开展医、教、研不可缺少的宝贵资料,也为医疗纠纷提供法律依据。自去年国务院颁发了《医疗事故处理条例》及卫生部颁发配套文件以来,病案的法律价值和佐证价值日显重要,病案不仅是医务人员业务思维行为选择的法律依据和基础,也是医
The medical record is the medical file of the patient. It fully and truly records the entire process of the patient’s disease development and records all the thinking and actions of the medical staff in the process of treating the patient. It is the original record of medical personnel carrying out medical activities, has important medical reference and utilization value, is indispensable valuable information for carrying out medicine, teaching and research, and also provides legal basis for medical disputes. Since the “Regulations on Handling Medical Accidents” issued by the State Council last year and supporting documents issued by the Ministry of Health, the legal value and supporting value of medical records have become increasingly important. Medical records are not only the legal basis and basis for the selection of thinking behaviors of medical personnel, but also medical services.