美国医疗过失诉讼中的病历审查

Reviewing the Medical Record in American Medical Malpractice Claims

临床病历资料中包含大量的、对诉讼有决定性影响的信息,因而对临床病历进行审查是医疗纠纷诉讼的基础。进行病历审查,需要具有医学思维和法学思维,鉴定人必须应用临床医学和法学的知识与经验才能完成病历审查。与此同时,鉴定人还必须能够区别哪些病历材料是可以粗略审查的,而哪些则是必须深入研究的。本文将介绍美国医疗过失索赔诉讼中的临床病历审查制度,主要包括两方面内容:一是确认病历审查的启动程序;二是掌握审查所需信息,并为确认潜在的医疗过失行为提供指导。

Medical records are the foundation of every medical malpractice claim investigation, which contains a great deal of information crucial to the investigation. Reviewing a medical record for claim investigation requires the development of a medical sense. That is, the investigator must apply clinical experience as well as concepts in law. Also required is the ability to differentiate between medical records that required only a cursory screening and those for which an in-depth review is necessary. The goal of this article is twofold： to instruct the investigator on how to determine when medical records require a review, and to explain how to extract the information needed to evaluate a case for potential liability.