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病案是临床医务人员的一种特殊的作品,具有独特的格式。每个医务工作者都必须充分认识到病案书写的重要,它是临床实践中经常进行的工作,是每个医务人员一生都要进行的工作。病案应是一种具有高度可靠性的科学性的永久记录。病案已成为医院的一‘宝’。它不仅是疾病的临床诊治、护理
The medical record is a special kind of work for clinical medical personnel and has a unique format. Each medical worker must fully understand the importance of medical record writing. It is a routine work in clinical practice and is a job that every medical worker must perform in his or her lifetime. The medical record should be a scientific and permanent record with high reliability. The medical record has become a ‘holy treasure’ for hospitals. It is not only the clinical diagnosis and treatment of diseases, nursing