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病历档案是人们在医院就医期间形成的全部医疗档案,即人们就医后由患者或家属陈述病情、病史以及医护人员对患者进行诊断、治疗、护理和愈后追踪过程中形成的全部记录(包括各种文字、图表,以及所有的实验室检查和其他特殊检查的报告等),它完整地记录了病人历次的检查、治疗和转归的全过程,以及与疾病有关的所有问题。病历档案从一定意义上讲也是临床医学的法定文件。因此,加强病历档案管理,有效地保护和利用病历档案,为医疗事业发展和社会各方面服务意义
The medical record is all the medical records that people form during hospital treatment, that is, all the records formed by the patients or their relatives after they get medical treatment, the medical history and the diagnosis, treatment, care and follow-up of the patients Kinds of words, charts, reports of all laboratory tests and other special examinations, etc.), which completely records the whole process of examination, treatment and outcome of the patients and all the problems related to the diseases. Medical records in a certain sense is also a statutory document of clinical medicine. Therefore, to strengthen the management of medical records, the effective protection and use of medical records, for the development of medical services and all aspects of social services