病案不但是医生对病人在医院诊治期间的全部医疗记录,又是医疗、教学和科研极其重要的信息资源,每一份病案都是临床实践的经验总结,也是医院的三大宝库之一,随着社会的发展和进步,医疗制度的改革,社会医疗保险制度的启动和人们对健康意识的重视,人们对病案资料的真实性、科学性 The medical record is not only the medical record of the doctor during the treatment of the patient in the hospital, but also an extremely important information resource for medical treatment, teaching and scientific research. Each medical case is a summary of clinical practice and is also one of the three treasure troves of the hospital. The development and progress of society, the reform of the medical system, the start of the social medical insurance system, and people’s awareness of health awareness, the authenticity and scientific nature of people’s medical records