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病例档案是对住院病人的观察、检查、治疗等活动中形成的真实的原始医疗信息资源。病例档案是衡量医疗质量和学术水平高低的重要依据,是医院管理的基础资料,又是医疗统计的原始资料。现就如何加强和提高病例档案管理工作,使其好地发挥应有的作用谈几点看法。
Case file is a real source of original medical information formed in the observation, examination, treatment and other activities of inpatients. Case file is an important basis for measuring the level of medical quality and academic level, is the basis of hospital management information, but also the original source of medical statistics. Now on how to strengthen and improve the management of case files, to make it well to play its due role to talk about several points.