电子病历的司法认定困境与出路探析——以医疗损害赔偿纠纷审判实务为视角

On Dilemma and Solutions of the Judicial Cognizance of Electronic Medical Records——From the Trials About the Compensation Disputes for Medical Damages

随着医院信息数字化的发展,电子病历受到了越来越广泛的关注。在司法实践中,以医疗损害赔偿纠纷为代表的案件屡屡涉及电子病历的认定问题。通过对近几年涉及电子病历案件的实证研究,以其中的医疗损害赔偿纠纷案件为样本,可以总结出其在司法审判实务中的责任分配比例及原因。目前,电子病历的真实性在认定上有上在困难,在技术尚不能取得突破的情况下,区分病历管理责任与损害赔偿责任,将病历管理责任作为医疗损害赔偿纠纷中的补充责任不失为一种较好的处理方法。

With the development of the hospital informatization, more and more attention has been paid to the electronic medical records which, in the judicial practice, are typically significant in the compensation disputes for the medical damages.Through the empirical research on the cases involving electronic medical records in recent years, the liability of each party in the judicial practice and the reasons for it can be concluded.In view of the dif-ficulties in the authentication of electronic medical records, under the condition of existing technology, it is a good method to distinguish the responsibility for medical records management ( as the supplementary liability in the medi-cal disputes) from the liability for medical damages.