医学文书作为证据的相关问题研究

目的 探讨医学文书作为证据应具备基本特征和法律责任。方法 应用证据学理论并结合有关法律法规， 对医学文书的证据材料属性和标准进行分析。结果 医学文书属公文性书证， 作为证据应具备下列标准： （１） 按卫生部门规定时限完成， 不能在诉讼后补写； （２） 出具的医学文书应是取得执业许可的医疗机构和医务人员； （３） 必须是医师亲自诊治、检查； （４） 出具医学文书内容和格式必须符合卫生行政部门要求。在医学临术实践中， 涉及法律诉讼有关医学文书存在种种缺陷。结论 医学文书作为证据已受到法医学、医学和法律界广泛关注， 医学文书不完整及各种改动、丢失、补写必然影响证据可靠性和可信度。出具虚假医学文书，

Basic character of medical documents as evidence and relevant problems. Deng Zhenhua , Liao Zhigang , Yi Xufu .et al. Departmentof Forensic Medicine, West China University of Medical Sciences. Cheng Du, 610044【Abstract】Objective To explorethe basic character and legal responsibility of medical documents as evidenceand relative problems. Methods Accordingto the theory of evidence and relativelaw and regulations,the propertyand standards ofevidential materialon medical documents were analyzed and classified byinductive method.ResultsThe property of medical documentsshould be considered to belong to official document evidence .Thestandards ofevidential materialon medical documents as follows:(1) Medical documents including hospital records must beenmadein stipulated timeestablished by hygeian administrative department;(2) Medical documents must be providedby qualified medicalunits and doctors;(3) Medicaldocuments mustberecorded by doctorselfafter checkup,diagnosis and treatment;(4) The form and contents of medical documents must be in accord with the demands ofhygeian administrative department.In clinical medicine practives ,considerable number of medicaldocuments associated withlawsuit haveserious problemssuch asspare,incomplete,sloppy ,overlook ,lose and altered orfalse medicalrecords.Conclusion As evidential material,theimportanceof medicaldocuments haveincreasingly been foundinthefieldsof medicine,forensic medicine and law . Admissible medical documents must been provided by qualifiedmedical units and professionaldoctors.Flawed medicalrecordsincluding incomplete,altered ,lose and postmedicaltreatmentrewriting will affect on the authority and credibility of medical evidence . The provider of falsemedicalrecords should be punished bylaw and regulations.【Key Words】Medical document Evidence Legal problem Forensic clinical medicine