病案是患者病情资料的汇总,是由医务人员书写整理而成的医疗文献,客观真实地记录了患者疾病的发生、发展、诊断、治疗及住院期间医疗活动的全过程,是所有医护人员逐时、逐日连续和及时分别记录的既统一又不绝对一致的患者疾病发生、发展、诊疗、护理、转归等情况客观和系统的记录所形成的 The medical record is a summary of the patient’s condition information and is a medical document written and arranged by the medical staff. The medical record objectively and truthfully records the whole process of the occurrence, development, diagnosis, treatment, and medical activities of the patient during the hospitalization and all medical staff hour by hour , Formed by objective and systematic records of occurrence, development, diagnosis, treatment, care and return of patients who were both consecutively and timely recorded in a unified and not absolutely consistent manner