从医患纠纷证据的角度规范病案管理

Standardizing medical records management from a view of the evidences of medical disputes

医院病案在处理医疗纠纷中是重要的法律证据,病案记录中的缺陷引发医疗纠纷会给医院或患者带来损害。病案真实性的因素存在于病案形成、管理的各个环节,通过对现行制度的严格执行或改进可以避免医疗隐患的出现。保障病案的证据价值的运用需要病案立法,健全病案法规和医务人员良好的病案意识,使规定病案的法律文件具有现实的可行性,病案成为医疗纠纷不可或缺的法律证据之一。

Analysis was done on the importance of medical records in medical disputes,as well as the effects of medical records defects on the medical disputes to clarify the factors influencing the truthfulness of medical records,which lie in every link of formation and management of medical records. We should strictly execute or improve existing system to ensure the evidential value of medical records.