现代病历的发展及其法律属性  

Development of Modern Medical Record and Its Legal Attribute

作　　者：王淼[1] 程瑞专[2] 

机构地区：[1]解放军总医院外科临床部,北京100853 [2]解放军第273医院,库尔勒841000

出　　处：《解放军医院管理杂志》2006年第3期252-253,共2页Hospital Administration Journal of Chinese People's Liberation Army

摘　　要：病历是指医务人员在医疗活动过程中形成的文字、符号、图表、影像、切片等资料的总和。病历不仅具有医学科学意义上的证据属性,而且还具有实施鉴定、明确责任、解决争议等法律意义上的证据属性。随着我国逐步进入信息化时代,电子病历已经在医疗卫生系统逐渐普及,也带来了一系列的问题,尤其是在我国还不具有明确的法律效力,所以进一步推广应用还需要做好两项工作:一是确立电子病历的法律标准和法律效力,针对电子病历进行有效的立法活动;二是针对我国医疗系统电子病历的实施现状,提出符合实际的、行之有效的管理办法。Medical records consist of many elements including words, symbols, charts, images and pathological sections, which are produced by medical personnel during medical treatments. They are of evidence attributes not only in the meaning of medical science, but also in the meaning of law to deal with medical disputes. Nowadays, electronic medical records are broadly used in medical system. However, many problems have been brought out by them, especially the lack of definite force effect at present. So to extend the uses of electronic medical records, two steps must be done. One is to establish legal standards of electronic medical records and confirm their legal validity, the other is to put forward effective and practical methods to manage electronic medical records.

关 键 词：电子病例 责任 法律属性 

分 类 号：R197.32[医药卫生—卫生事业管理]