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、业务素质和医疗水平。病案也是病人医疗全过程的文字记载,更是医疗保险理赔、解决医疗纠纷、判定法律责任的事实依据,因此病案管理是医院管理工作的重要组成部分。我院建立于1918 Medical record is the basis of clinical diagnosis and treatment work and concluded that medical research is an important reference. It directly reflects the health care workers medical knowledge, professional quality and medical standards. Medical records are also the whole process of patient medical records, but also medical insurance claims, to resolve medical disputes, to determine the legal basis for the factual basis, the case management is an important part of hospital management. Our hospital was established in 1918