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病案是患者诊疗、救治过程的原始资料。病案首页既是病案的窗口也是病案的精髓,它是整份病案当中内容最集中、最核心的部分。其所提供的100多个填写项目涵盖了病案的方方面面,是病案信息的引导。
The medical record is the original data of the patient’s medical treatment and treatment process. The medical record is not only the window of the medical record but also the essence of the medical record. It is the most centralized and most central part of the entire medical record. The more than 100 items it provides cover all aspects of the medical record and is the guide to medical record information.