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病案是临床医生诊疗工作的依据和总结,是医教研的重要参考资料,它直接反映了医护人员的医学知识、业务素质和工作能力,病案也是病人医疗全过程的文字记载,是医疗纠纷处理的法律依据。因此病案管理是医院管理工作的重要组成部分,规范病案借阅行为是开发利用病案信息资源的主要前
The medical record is the basis and summary of the clinician’s diagnosis and treatment work. It is an important reference material for medical education and research. It directly reflects the medical knowledge, professional quality and work ability of the medical staff. The medical record is also a written record of the patient’s medical treatment, and it is a medical dispute process. Legal basis. Therefore, medical record management is an important part of hospital management. Regulating medical record borrowing behavior is the main process for the development and utilization of medical record information resources.