护理病历中的法律风险及其预防机制研究

Study on legal risk in nursing medical records and its prevention mechanism

在医疗损害责任纠纷的处理中,护理病历是证明医疗机构护理行为有无过错最直接、客观的证据,是医疗事故技术鉴定或医疗损害鉴定的重要依据。司法实践中因临床护理病历管理、书写不规范导致医方在医疗损害责任中被认定过错的情形屡见不鲜。通过对这类纠纷的实证分析,总结了我国医护实践中护理病历存在的常见问题,提出相应的解决措施,旨在为医疗机构依法执护、建立护理安全系统提供参考。

In the treatment of medical damage liability disputes, nursing medical record is the most direct and objective evidence to prove whether the nursing behavior of medical institutions is wrong or not. It is an important basis for medical accident technical appraisal or medical damage appraisal. In judicial practice, it is common for doctors to be identified as fault in medical damage liability due to non-standard management and writing of clinical nursing medical records. Through the empirical analysis of such disputes, this paper summarized the common problems existing in nursing medical records in medical practice, and put forward corresponding solutions, in order to provide reference for medical institutions to implement nursing according to law and establish nursing safety system.