由侵权责任法看医院病案管理的风险

A Discussion on Risk of Medical Record Management of a Hospital by Tort Liability Law

目的基于医院病案管理现状,探讨规范病案的制作和管理,进一步减少医疗纠纷。方法解读《侵权责任法》与病案相关的法律条文,对案例进行分析。结果手写病历和电子病案均存在管理缺陷,易出现书写不规范、记录不及时、项目不完整、内容失真等问题。结论医疗机构能够在纠纷发生时提供真实完整的病案资料,有利于对医疗损害责任的成立与否作出认定,降低败诉风险。

Objective Based on the situation of hospital medical record management,this paper investigate the methods of standardizing the production and management of medical record for further reducing medical tangle.Methods It analyses cases through interpretating law articles related to medical record in Tort Liability Law.Results There are management defects both in handwriting and electronic medical record,easily appearing non-standard writing,non-timely record,incomplete program and distortion content.Conclusions Medical institute can provide real and complete medical record when medical tangle happen,which is benefit for determination of medical liability for damage,reducing risk of losing lawsuits.