大家都知道病历是军医用来记录病员疾病的发生、病程经过、治疗方法及效果,出院时病员的健康状况和去向的原始医疗文件。它是说明医疗机关医疗工作质量的主要依据,也是研究提高医疗工作质量的主要资料;在因公受伤、残废等情况下,更有着法律上的意义。但在写病历时,各人写的项目不可能一致;而 Everyone knows that medical records are used by military doctors to record the occurrence of disease, the course of the disease, the treatment methods and effects, the medical condition of the sick at discharge, and the original medical documents. It is the main basis for illustrating the quality of medical work in medical institutions and the primary source of information on improving the quality of medical work. It is even more legally meaningful in cases of injury or disability. However, when writing the medical record, the items written by each person can not be consistent;