Medical record is a record of the occurrence, development, outcome, examination, diagnosis and treatment of patients' diseases. It is also a patient's medical and health record written in accordance with the prescribed format and requirements by summarizing, sorting and comprehensively analyzing the collected data. Medical records are not only the summary of clinical practice, but also the legal basis for exploring the laws of diseases and handling medical disputes. Medical record plays an important role in medical treatment, prevention, teaching, scientific research and hospital management.

Extended data

Main functions:

(1), medical care: medical records are not only the data for diagnosis, treatment and preventive measures, but also the basis for medical staff to evaluate the level of disease diagnosis and treatment, and it is also an important reference for the diagnosis and treatment of patients when they come back.

(2) Teaching: Medical records are valuable materials for teaching and the most vivid teaching materials. Through the writing and reading of medical records, the medical theory and practice are closely combined, the learned knowledge is consolidated, the horizons are broadened, and the logical thinking ability and rigorous medical style of medical staff and medical students are cultivated.

(3) Scientific research: Medical records are the main data of clinical research. Through the summary and analysis of clinical medical records, we seek the objective laws and internal relations of the occurrence, development and treatment outcome of diseases, study the relationship between clinical treatment and preventive measures and diseases and rehabilitation, discover and screen new medical technologies and drugs, and promote the continuous development of medicine.

(4) Hospital management: Through the analysis of a large number of medical records, we can objectively reflect the hospital management level such as hospital working conditions, technical quality, medical quality, management measures and medical ethics. A lot of data in medical records are important indicators of national health statistics.

(5) Disease prevention: Through the classified statistics and analysis of medical records, we can understand the implementation of the "three-level prevention" principle, the implementation of disease prevention and disability prevention measures, and the occurrence and development of various common diseases and frequently-occurring diseases, so as to provide a basis for controlling and implementing preventive measures and implementing the policy of putting prevention first.

(6) Law: Medical records are the legal basis for handling medical accidents and medical disputes. Therefore, medical records are important documents to effectively protect the legitimate rights and interests of patients and medical staff.

Baidu Encyclopedia-Medical Records