试论病历书写者的法律责任和应对措施

Responsibility and Measure of Medical Record

病历是司法程序中的重要书证已毋需怀疑,作为病历书写者也就自然成了书证的最主要的作者,而书证是审判过程中的重要证据之一,这体现了病历书写质量与法律的最基本的相关性和重要性。而临床上部分病历书写者没有充分认识到病历的法律重要性,以致随意涂改、伪造查房记录、主观编造体征、故意歪曲事实、遗留重要病情等现象时有发生,严重影响了病历的真实性和严肃性。因此加强法制教育、提高自身素质、严格遵守标准、实施科学管理、院科及个人抓好病历质量控制是保证病历质量的重要措施。

No suspicion that the medical record is important documented evidence. The Writers of Medical Record are the primary writers of the documented evidence and it surely becomes one of important evidence in the entire course of a judicial proceeding, this shows the importance and the basic pertinence. Some writers of medical record in the clinic absence plenary haven't known that the medical record was so essential in law that they altered arbitrarily, counterfeited the medical record, faked the base character subjectively, distorted the fact purposely, and left behind the serious diseases and so on. Those above took place often.