从证据角度谈病历的书写

Discussion on Writing of Medical Records from the Point of View of Proof.

客观、真实、准确、及时、完整记载的病历资料是证明医疗行为是否合法、适当、必要、安全的强有力的证据资料。以往病历的书写往往没有想到它的证据作用 ,因而常不符合证据法的要求 ,以至于使其失去证据的资格 ,或者虽有证据资格但证明力较弱。文章主要从民事诉讼证据的角度探讨应当如何书写病历 ,建议使用事实陈述语言 ,记载的内容真实、合法。

Objective, actual, accurate, timely and complete medical record materials are powerful proofs to prove whether medical behavior is legal, proper, necessary and safe. Past medical records always could not meet requirements in Law of Proof for ignoring its role as proof, which lost its qualification as proof, or though it could be regarded as proof, it power was very weak. From the point of view of civilian lawsuit proof, this paper discusses how to write medical records. It should use fact presentation language and the contents should be true, legal and standard.