病案作为载体,是疾病诊治的全程记录。病案体现了一所医院的医疗质量,科技水平和经营管理的能力。抓好病案质量是提高医务人员业务素质的基本途径和加强医疗质量控制的重要环节,也是医院现代化建设的重要内容。随着医院改革的深化和医学科技的发展,医院经营和管理模式、诊疗和 The medical record as a carrier is the full record of disease diagnosis and treatment. The medical record reflects the hospital’s medical quality, technological level, and management and management capabilities. Grasping the quality of medical records is a basic way to improve the professional quality of medical personnel and an important link in strengthening medical quality control. It is also an important part of hospital modernization. With the deepening of hospital reform and the development of medical science and technology, hospital management and management models, diagnosis and treatment, and