医疗过程中法律证据的收集  

Collection of Legal Evidence during Medical Process

作　　者：黄莉[1] 黄涛[2] 

机构地区：[1]四川省泸州医学院附属医院血液内科 [2]四川省泸州医学院附属医院网络中心

出　　处：《中国病案》2012年第2期59-60,共2页Chinese Medical Record

摘　　要：提高医院临床医师在医疗过程中收集有效法律证据的意识,防范医疗纠纷。提高证据意识,从术前告知、患者对诊疗方法的自主决定、认定患者具有行使知情同意能力、以及患者家属是否同意尸检、死亡诊断的证据等;对可导致医疗纠纷的常见原因强调对法律证据的收集。强化病案记录的内在质量,提高病案的内涵质量,使病案成为举证责任倒置重要的举证依据。强化在医疗过程中对有效法律证据的收集并依法记录病案的意识,有利于防范医疗纠纷,维护病人、医院、医务人员的合法权益。To improve hospital clinicians＇ awareness in legal evidence collection during of medical process,and to prevent medical disputes.Legal evidence of medical process include inform before surgery,patient＇s own decision on the treatment method,identify patients with the ability to exercise informed consent,agree to an autopsy of patients family members,and death diagnosis.The collection of law evidence should be emphasized on the common cause which could lead to medical malpractice.To enhance the intrinsic quality of medical records and improve the quality of medical record content,so that medical records become an important burden of proof based on evidence.Strengthen the awareness of collection of law evidence and write medical records by law,which will help to prevent medical malpractice and the legal rights of patient,hospital andmedical staff will be protected.

关 键 词：医疗过程 法律证据 病案记录 医疗纠纷 

分 类 号：R-051[医药卫生]