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病历档案是医务人员记录疾病诊疗过程形成的文件材料,是病人在当次发病中的病情经过、疾病诊断、治疗、护理和疗效的记录,它客观、完整、连续地记录了病人的疾病诊疗经过,是评价和衡量医院技术管理水平和医疗质量的重要依据,也是临床、教学、科研和医院管理不可缺少的资料,以及医疗事故纠纷、法律诉讼中的法定证据。
Medical records are records of medical staff records of the formation of the disease diagnosis and treatment process is the patient’s condition in the incidence after the disease diagnosis, treatment, care and efficacy of the record, it objectively, completely and continuously recorded the patient’s disease after treatment Is an important basis for evaluating and measuring the technical management level and medical quality of hospitals. It is also an indispensable piece of information for clinical, teaching, scientific research and hospital management as well as legal evidence in medical malpractice disputes and legal proceedings.