完善的病历档案是医疗工作的全面记录,客观地反映了疾病诊断、治疗及其转归的全过程。病历档案是医疗活动信息的主要载体、科研的良好素材,也是评价医院医疗质量、技术水平、管理水平的依据,是发生医疗纠纷时医院举证的重要依据,特别是近年来, Perfect medical records are comprehensive records of medical work and objectively reflect the whole process of disease diagnosis, treatment and its outcome. Medical record files are the main carrier of medical activity information and good materials for scientific research. They are also the basis for evaluating hospital medical quality, technical level, and management level. They are an important basis for hospital certification when medical disputes occur, especially in recent years.