司法鉴定的病历缺陷分析  

Analysis on the Defects Existing in Medical Records with Judicial Identification

作　　者：张红宇[1] 白家琪[1] 杜淑英[1] 赵国光[1] 

机构地区：[1]首都医科大学宣武医院医务社会工作部,北京市100053

出　　处：《中国病案》2015年第11期15-16,96,共3页Chinese Medical Record

基　　金：首都医科大学校长基金(13JYⅣY70)

摘　　要：病历是医务人员在医疗活动过程中形成的、兼具医学意义和法律意义的医疗法律文书。当医疗纠纷通过诉讼途径解决时,司法鉴定以病历为依据,鉴定意见对判决起关键性作用。对某院2013年至2014年间21例司法鉴定报告进行分析,其中有病历缺陷的占76.2%,主要问题集中在围手术期风险评估、病情分析等病历记录问题,术前手术知情同意和替代医疗方案的告知,以及死亡病历尸检告知问题。因此以司法鉴定为鉴,培养医务人员病历书写的法律意识,强化病历质控,在法律层面上进一步规范病历书写,尊重患者的知情权、选择权,切实履行医务人员的告知义务,从而提高病历书写质量,防范医疗风险。Medical records are medical legal documents which are formed by medical personnel in medical activities, both having medical and legal significance. Judicial identification bases on medical records and plays a key role in the decision of the court. Defective medical records accounted for 76.2% by the analysis of 21 cases of judicial identification report from 2013 to 2014. The main problem concentrated on peri-operative risk assessment, condition analysis of medical records, informed consent about the pre-operation, alternative treatment scheme, and autopsy. Judicial identification report is a warning. It is important to train the legal consciousness of medical staff in medical record writing, strengthen quality control of medical records, standardize the medical record writing on the legal level. In addition, medical staff must respect the patient＇s right of informed and select consent, fulfill the duty of disclosure to improve the quality of medical records writing and prevent medical risk.

关 键 词：司法鉴定 病历 缺陷 

分 类 号：R197.323[医药卫生—卫生事业管理]