入院记录中患方确认签字制度的法律思考

A Legal Reflection on Validation Signature System on Resident Admit Note

入院记录内容的客观真实性是影响病历作为证据使用的重要因素,入院记录中患方确认签字是保障入院记录真实性的积极探索。目前患方确认签字制度面临法律法规不明确、患者不配合等诸多问题,需要通过加强立法对患方签字权予以确认,通过修订相关规章制度来保障病历资料的客观真实性,为规范诊疗、提高病历证据效力提供法律支撑。

The validity of resident admit note is a key factor that determines whether the note can be taken as a testimony in a medical dispute or not. The patient＇s validation signature is a positive attempt to guarantee the validity of resident admit note. Currently there are a series of insufficiencies in patients＇validation signature system, including indefinite legislation, patients＇ uncooperative attitude, etc. Therefore, certain legislation is in great need to validate patients＇ right of signature and safeguard the validation of resident admit note, thus providing legal support for regulating medical activities and improving the validity of medical notes as testimonies in medical disputes.