病案是以文字形式记录病人住院期间症状体征、诊断、治疗、用药、护理、检查等医疗活动的全过程,它不仅是医务人员医疗质量业务水平的具体表现,也是健康体检、医疗保险、伤残鉴定及某些意外伤害医疗纠纷的重要依据,具有法律效力。随着社会的发展和进步,人们的法律意识、健康意 The medical record is a written record of the whole process of medical activities such as symptoms, signs, diagnosis, treatment, medication, nursing, and examination during hospitalization. It is not only a concrete manifestation of medical staff’s medical quality business level, but also a health examination, medical insurance, and disability. The identification and the important basis for certain accidental injury medical disputes have legal effect. With the development and progress of society, people’s legal awareness and healthy intentions