Note: There are differences in different regions for reference only.
Medical records are records of medical activities such as the occurrence, development, prognosis, examination, diagnosis and treatment of 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, and are the precious wealth of the country. Medical record plays an important role in medical treatment, prevention, teaching, scientific research and hospital management.
brief introduction
Medical record, also called medical history, is a written record of the patient's condition and treatment. Medical records are the basis for doctors to diagnose and treat diseases, and are valuable materials for medical research.
As early as the 6th century BC, from a village in the Peloponnesian Peninsula on the east coast of Argolis Bay in ancient Greece, there stood a statue of Ackell Pioz, the god of medicine. Almost every day, many patients come here to worship and pray for an early cure of their diseases. To this end, the priests in the temple specially set aside a room to treat these pious patients, and recorded the condition, symptoms and treatment results of each patient one by one, and kept them as personal medical records. This is the earliest medical record in the world.
Chunyu Kun, a famous doctor in the early Han Dynasty, was the first doctor who invented and used medical records in China.
Chunyu Kun, a native of Linzi, Shandong Province, was also named as Qi Taicang. Chunyuyi is eager to study medicine. He got the "magic prescription" and "strategy" from the famous teacher Gongsun Optics, and got the pulse book and five-color diagnosis method of Huangdi and Bian Que from Gongcheng Yang Qing, and his medical skills became more and more profound. During the reign of Emperor Wen of Han Dynasty, Chunyu Kun was falsely accused and Chunyu Kun was imprisoned. His daughter Chunyu Ti Ying wrote to the emperor, asking him to be a handmaiden in the palace to redeem her father. When the emperor saw it, he felt very sorry for her, so he pardoned Chunyu Kun.
In the long-term medical practice, Chunyuyi deeply felt that if the patient's chief complaint is not recorded, it is not enough to rely solely on the doctor's memory, because the doctor's memory is inaccurate, which often brings difficulties to treatment.
Reference from Baidu Encyclopedia
References:
/view/ 1098 12.htm