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病历档案是病人在就医过程中,由医师对其疾病诊疗情况的重点和系统记载,它是病人在医院就医期间所形成的全部医疗档案,包括各种诊疗文字、图表、实验室检查和其他特殊检查报告等资料。病历档案不仅是记载病人就诊、住院期间病情变化及诊断过程的原始资料,也是评价和衡量医院管理、医疗文书和技术水平的重要依据。随着国家法律制度的不断完善,病历
Medical record is the patient in the process of medical treatment, by doctors on their disease diagnosis and treatment of the focus and systematic records, it is the patient during the hospital medical treatment formed during the entire medical files, including a variety of medical texts, charts, laboratory tests and other special Inspection reports and other information. The records of medical records are not only the original data recording the patient’s visit, the changes of the condition during the hospitalization and the diagnosis process, but also the important basis for evaluating and measuring the hospital management, medical instruments and technical level. With the continuous improvement of the national legal system, medical records