法学视域中的病历及其作用实现

The Function and Its Achievement of Medical Record in the Legal Sight

病历是处理医疗纠纷最直接、最重要的书面证据,其所有权的归属决定着病历的法律地位。现行病历管理制度在操作过程中存在着许多问题,特别是在病历真实性问题上饱受争议,熊卓为一案在很大程度上反映了这种问题的现实意义。通过病历固定编页制度及患者签名制度可以强化对病历真实性的保障。

Medical records is the most direct and important documentary evidence of dealing with medical disputes. The problems of the recent medical records management system still exist in the process of operation and the situations,for example,medical records were tampered and scribbled occur frequently. It is known that Medical records play an important role in the process medical dispute. In order to avoid obstacles which unreal medical records causes in the course of medical dispute, further efforts and measures to the improvement of Medical record Numbering System and Medical record Signature System should be adopted in the future.