医院病案的证据作用及其管理对策研究  

Discussion on thd Fanction of Medical Record as Legal Evidence and Management Countermeasure

作　　者：杨琳[1] 赵军[1] 李泽华[1] 

机构地区：[1]湖北医药学院公共管理学院,十堰442000

出　　处：《医学与社会》2014年第1期73-75,共3页Medicine and Society

基　　金：2012年湖北省人文社科指导性项目成果;编号为2012G145

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,其证据属性应从"证据能力"和"证明力"角度来构建。对病案的管理要求,医疗机构应合法、客观、具备关联性进行管理。但实践中病案的证据价值却因书写、保管、质量监控等环节的不规范而严重受损。同时,在电子病历的推广使用中也出现了新的技术问题,导致其证明力受损。因此,只有提高医务人员的病案证据意识、依法规范病案的书写与保管、建立严格的电子病历信息系统、完善病案的质控体系,才能最大程度的发挥病案的证据作用。The medical record is the real objective medical records in medical practices. Its attribute of evidence should be met with ＂evidence ability＂ and ＂proof strength＂ , which require legal, objective, and having relevance, But in practice, the evidence value of medical records is severely damaged due to the non - standard writing, storage, management, and quality control. The proof strength is also damaged in the use of electronic medical records because of new technical problems. Therefore, we must improve the medical staff~ legal awareness of medical records, standardize the writing and safekeeping of medical records, establish a strict electronic medical records system, and perfect the system of quality control of medical records, in order to enhance the evidential value of medical records in the greatest degree.

关 键 词：医疗机构 病案管理 电子病历 

分 类 号：R197.3[医药卫生—卫生事业管理]