病历书写不规范的法律责任探讨  

Legal liability of nonstandard writing of medical records

作　　者：黎毅 彭一林 黄静筠 罗柳明 Li Yi;Peng Yilin;Huang Jingyun;Luo Liuming(Foshan Health Superoision Institute,Foshan,Guangdong 528000,China)

机构地区：[1]佛山市卫生监督所,广东佛山市528000

出　　处：《中国卫生法制》2023年第6期100-108,共9页China Health Law

摘　　要：随着社会发展、普法工作的深入推进,人们维权意识不断增强。当出现医疗纠纷时,医疗机构作为医方,患者及其家属作为患方,两者之间除了协商解决以外,更多的是通过行政和司法途径来处理此类纠纷。医疗活动有复杂性、专业性等特点。医患双方存在知识面、信息面不对等的情况,产生纠纷后如何认定法律责任,成为司法机关和行政机关的处理难点。病历作为记载医疗活动的重要书面资料,成为预防和处理各种纠纷的关键材料。结合医疗纠纷预防和处理的实践,对病历书写不规范所产生的刑事责任、民事责任和行政责任,以及司法机关、行政机关的处理等重点内容展开探讨。With the development of society and the popularization of law,peoples concept of legal awareness are constantly enhanced.When medical disputes occur,besides consultation,medical institutions,patients and their families are more willing to solve the problem through administrative resolution and judicial decision.Medical activities are complex and professional.The information of patients and doctors is not equal.It is difficult for judicial and administrative departments to determine legal responsibility.As an important written evidence for recording medical activities,medical records have become the key material for preventing and solving disputes.Based on the experience in prevention and solution of medical disputes,this study focused on the criminal liability,civil liability and administrative liability arising from the nonstandard writing of medical records,as well as the handling of judicial and administrative departments.

关 键 词：医疗纠纷 病历 法律责任 

分 类 号：D902[政治法律—法学理论]