病历即医疗纪录的集合，是民众至医疗机构接受医疗服务的所有医事相关纪录。

病历数据源基本上是由医务人员，如医师、护理师、医技、麻配师、复健师、营养师等，在问诊、体格检查、辅助检查、诊断、治疗、护理等医疗活动过程中形成的文本、符号、图表、影像、切片、检查结果等资料。

病历不仅记录病情，而且也记录医师对病情的分析、诊断、治疗、护理的过程，对预后的估计，以及各级医师查房和会诊的意见。因此，病历既是病情的实际记录，也是医疗、护理质量和学术水平的反映。

随着信息技术的进步，部份医疗院所开始导入电子病历，医务人员改以电脑或是PDA等设备记录病历及开立药方，X光片改以电脑文件保存。

The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. The medical record includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.