病案管理与法律意识

Medical Record Management and law consciousness

目的探讨病案管理在医疗侵权诉讼中的法律意义,使医务人员从思想上提高认识,加强自我意识,不断培养法律观念,在医务工作中立于不败之地。方法通过对《医疗事故处理条例》中提出的“举证责任倒置”的分析和揭示当前病案管理存在的一些现状,论证病案管理法律意义的重要性。结果保证病案管理客观、真实、完整,一靠法律,二靠自律。结论提高医务人员的法律观念和病案管理的法制化是医疗机构乃至医学界的重要议题。

Objective To discuss the significance of medical record management in medical litigation. The aim of the paper is to enhance the sense and awareness of self-protection of the medical workers. Methods The importance of legal significance of medical record management was proved through the analysis of Evidence Provided by Litigant which was mentioned in The Regulations for Medical Accident Treatment and it revealed the current situation of medical record management. Result It is law and self-discipline to ensure the objectiveness, trueness and completeness of the medical record management. Conclusion It is the important issues to enhance the legal consciousnesses of the medical workers and to make medical record management legalized in medical institute, even in the whole medical field.