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病历是医务人员在医疗活动过程中形成的、兼具医学意义和法律意义的医疗法律文书。当医疗纠纷通过诉讼途径解决时,司法鉴定以病历为依据,鉴定意见对判决起关键性作用。对某院2013年至2014年间21例司法鉴定报告进行分析,其中有病历缺陷的占76.2%,主要问题集中在围手术期风险评估、病情分析等病历记录问题,术前手术知情同意和替代医疗方案的告知,以及死亡病历尸检告知问题。因此以司法鉴定为鉴,培养医务人员病历书写的法律意识,强化病历质控,在法律层面上进一步规范病历书写,尊重患者的知情权、选择权,切实履行医务人员的告知义务,从而提高病历书写质量,防范医疗风险。
Medical records are formed during the medical activities of medical staff, both medical and legal significance of the medical legal instruments. When medical disputes are settled through litigation, the judicial appraisal is based on the medical record, and the appraisal opinion plays a key role in the verdict. The analysis of 21 forensic reports of a hospital from 2013 to 2014 showed that there were 76.2% of the cases with medical records defects. The main problems were the perioperative risk assessment, medical history records such as the condition analysis, informed consent of preoperative surgery and alternative medical care Notification of the program, and the issue of autopsy of death records. Therefore, taking forensic identification as a reference, we should cultivate legal awareness of medical records writing, strengthen the quality control of medical records, further standardize medical record writing on the legal level, respect the patient’s right to know and choose, and earnestly fulfill the obligation of informing medical staff so as to enhance the medical records Writing quality, prevent medical risks.