计算机打印病历的证据效力认定

Identification of evidence effect of computer print medical records

目的对计算机打印病历作为证据使用时的效力认定进行研究探讨。方法具体分析了近期我院1192份计算机打印病历的基本状况及作为证据使用时存在的效力认定情况,并据此提出增强计算机打印病历法律证据效力的具体对策。结果医疗机构利用计算机和网络系统,改进了传统手写纸质病历繁琐且沉闷的工作,积极提高了医务人员的工作效率,把更多的时间交还给了患者,将实质工作放在了诊疗上,提升了诊疗水平,但因为一些制度的不完善和具体措施落实不到位,让计算机打印病历从法律的角度分析还存在着一定的证据风险。结论应用一套全面而完善的计算机打印病历管理模式不但可以提高医疗机构的诊疗效率和医疗质量,还可以为医疗纠纷的处理提供合法、真实、客观的法律证据作用,这在整个医疗系统中是非常值得广泛推广使用的。

Objective To study the validity of the computer print medical record as the evidence used. Methods The basic status of 1192 computer print medical records in our hospital in recent years and the status of the validity as the evidence were analyzed.On the basis of this,the concrete countermeasures to enhance the validity of the legal evidence of the computer printing of medical records were put forward.Results Medical institutions use computer and network system,the traditional handwritten paper medical record tedious and boring work were improved,the efficiency of medical personnel was actively improved,more time to the patient was return,the substantive work was put on the diagnosis and treatment,the level of diagnosis and treatment was improved.However,becanse some systems were not perfect and specific measures were not implemented in place,there was still a certain risk of evidence for the analysis of computer-printed medical records from the legal point of view. Conclusion The application of a comprehensive and perfect computer print medical record management model can not only improve the efficiency of medical institutions and medical quality,but also provide legal,real and objective legal evidence for the treatment＇of medical disputes,which is Very worthy of wide application in the whole medical system.