摘要
病案是在医疗行为过程中形成的客观真实的诊疗记录,作为书证和原始证据在在医疗事故鉴定和医疗纠纷诉讼中具有重要的证据作用。然而实务中病案却存在记录不真实、保管不完整、质控不完善、认识不当等各种问题,使病案作为证据使用时存在较大瑕疵,严重影响医疗机构的举证能力。因此有必要严格病案的书写与保管、监控,确保病案的真实、客观,提高广大医务人员的相应法律意识,提升病案的证据价值。
Medical records are objective real diagnosis and treat records in the process of medical behavior, which play an important role in the medical accidents and medical dispute lawsuit as documentary evidence and primary evidence. However, some problems such as untrue records, incomplete storage, imperfect quality control, improper understanding were existed in the practice. These problems, which make the records larger defects as evidence, seriously affect the ability of proof of medical institutions. Therefore, it is necessary to strict medical records writing, storage and monitoring, in order to ensure that the medical records are real and objective, improve the legal aware- ness of medical staff, enhance the evidential value of medical records.
出处
《中国病案》
2014年第1期34-35,共2页
Chinese Medical Record
基金
2011年湖北医药学院人文社科项目(2011QDRW-17)
关键词
病历档案
证据能力
病案的证据价值
病案管理
Medical records
Evidence of ability
The evidential value of the medical record
Medical records management
