行政处罚中对伪造、篡改病历的认定

Identification of forging and tampering of medical records in administrative penalty

伪造病历与篡改病历都是含有特定目的的主观故意行为,二者不是排斥关系,都是未按规定填(书)写病历的特殊情形。行政处罚中对伪造、篡改病历的认定,不能简单照搬民事规定中有无“实质性影响”的原则;行政认定重在考察行为性质,行为是否造成病历真伪不明的结果不是认定的必要条件。根据制作病历的主体、方式、内容、目的,可对是否构成伪造、篡改作出认定。对目的的认定是一个证据运用或推定的过程。

Forging medical records and tampering with medical records are subjective and intentional acts with specific purposes. They are not exclusive relations. They are special situations in which medical records are not filled in or written according to regulations. The identification of forging and tampering of medical records in administrative penalty can not simply copy the principle of whether there is "substantial impact" in civil provisions. Administrative identification pays more attention to the nature of action. Whethe the action causes the result of unclear authenticity of medical records is not a necessary condition for identification. According to the subject, method, content and purpose of making medical records, it can be determined whether it constitutes forgery and tampering. The indirect proof of purpose is a problem of application or presumption of evidence.