电子病历真实性争议的司法实证研究  

An empirical judicial case study on the authenticity disputes of electronic medical records

作　　者：张雪晖[1] 李跃平[2] 张晨韵[1] Zhang Xuehui;Li Yueping;Zhang Chenyun(Public Health School of Fujian Medical University,Fuzhou 350122,China;Health Research Institute of Fujian Medical University,Research Center for Healthcare Reform and Development of Fujian,Fuzhou 350122,China)

机构地区：[1]福建医科大学公共卫生学院,福州350122 [2]福建医科大学卫生健康研究院,福建省医疗改革与发展研究中心,福州350122

出　　处：《中华医院管理杂志》2021年第2期158-162,共5页Chinese Journal of Hospital Administration

基　　金：福建省科技厅软科学项目(2019R0053);福建省卫生健康软科学项目(2019-RK-7)。

摘　　要：作者通过对近3年来涉及电子病历真实性争议的司法案件进行研究,发现因为电子病历存在特殊表现形式,在司法裁判中存在对电子病历真实性判定标准不一、电子病历鉴定普及率较低以及责任归属认定不一致的裁判困境。为有效推行电子病历系统应用,可以从统一电子病历系统建设标准、加强医疗机构电子病历管理和委托第三方存储方面进行诉前预防,确保其证据力;通过确定病历真实性的认定标准、完善电子病历司法鉴定制度和明确病历不真实的责任归属方面完善该类医疗损害案件的诉中处置。Based on a research on judicial cases concerning the authenticity of electronic medical records in the past three years,the authors encountered judicial dilemmas in judicial practice.The challenges arise due to the special manifestations of electronic medical records,unclear and disputable criteria for the authenticity of electronic medical records,low application level of electronic medical records identification,and inconsistent responsibility attribution.In order to effectively apply the electronic medical record system,it is recommend to promote pre-litigation prevention by unifying the construction standards of the computerized patient record system,strengthening hospital electronic medical record management and entrusting third-party storage to ensure the evidential weight.In addition,it is necessary to establish standards for authenticity of medical records,improve the electronic medical record forensic identification system and clarify the attribution of the responsibility for untrue medical records,so as to improve the handling of such medical damage cases during litigation.

关 键 词：电子病历 真实性 司法案件 实证研究 

分 类 号：D925.1[政治法律—诉讼法学] R197.323[政治法律—法学]