从医疗事故技术鉴定角度谈病历书写存在的问题

Discussions on the Problems in Medical Record from the Perspective of Technical Appraisal for Medical Accidents

近年来,随着人们维权意识地不断增强,在医疗诉讼中,当事人对病历真实性的关注度也在逐年提高;其一旦发现病历中存在瑕疵或涂改的情况,将会对整个病历提出质疑,从而导致鉴定工作不能正常进行,不仅会激化医患矛盾,而且会延长案件审理周期,严重阻碍了医疗纠纷的解决。鉴此,加强医院病历管理,提高医务人员病历书写质量,对减少或杜绝此类医疗纠纷显得十分必要。

In recent years, with people＇s increasing awareness of right protection, in medical litigation, the parties＇ focus on the reality of medical records also is increasing year by year. Once the parties found flaws or correction, they would challenge the whole medical records, which leads to the difficulties in proper appraisal.This not only intensified the doctor-patient contradiction, but also extended the trial period, and seriously hindered the solution of medical disputes. As a result, in order to reduce or eliminate this kind of medical disputes, it is necessary for the hospitals to strengthen medical record management, for medical staff to improve the quality of medical records.