病案是医务人员在诊疗护理活动的原始记载,记着有关疾病的发生、发展及变化过程,是诊疗经过和果诸方面的重要资料。病案书写质量不但真实地反一所医院的管理水平、医疗质量和医护人员的业务质,也是临床教学、科研、信息管理不可缺少的资料,是重要的医疗法律文书,也从一个侧面反 Medical records are the original records of medical staff in the treatment and care activities, keeping in mind the occurrence, development and change process of the disease, and are important information in various aspects of diagnosis and treatment. The quality of medical record writing is not only true. The management level of a hospital, the quality of medical care and the quality of medical personnel are also indispensable materials for clinical teaching, scientific research and information management. It is also an important medical legal document.