法医学鉴定中的医疗文书审查

Examination of Medical Document in Appraisal of Forensic Medicine

法医学伤情鉴定多需借助医疗单位出具的医疗文书来确定伤情程度,如诊断证明书、病历、检查报告单等。医疗文书往往因为医生的技术水平、责任心及其他人为原因而发生偏差,所以法医在将医疗文书用作鉴定依据时,要审查医疗文书的真实性、关联性和合法性。审查医疗文书一般采用判断证据的方法,即对医疗文书来源的合法性、客观性,诊断依据的真实性、可靠性,诊断结论的科学性、全面性进行审查;以及将医疗文书与同案其他证据加以对照、比较和验证;甚至收集新的证据,以消除医疗文书中的矛盾,确保其准确无误,为法医鉴定提供真实、可靠的医学依据。

The condition of an injury in forensic medicine is mostly determined by the medical document given by the medical unit. Because the medical document is inaccurate due to the technical level and responsibility of doctor and other reasons, the legal medical expert will examine its authenticity and legality when it is used as the appraisal basis. Its method is as same as the judgment of evidence.