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病案是在医疗行为过程中形成的客观真实的诊疗记录,作为书证和原始证据在在医疗事故鉴定和医疗纠纷诉讼中具有重要的证据作用。然而实务中病案却存在记录不真实、保管不完整、质控不完善、认识不当等各种问题,使病案作为证据使用时存在较大瑕疵,严重影响医疗机构的举证能力。因此有必要严格病案的书写与保管、监控,确保病案的真实、客观,提高广大医务人员的相应法律意识,提升病案的证据价值。
Medical records are objective and true medical records formed during the course of medical behaviors. As medical records and original evidence, medical records play an important role in medical malpractice and medical disputes litigation. However, in practice, the medical records have various problems such as untrue records, incomplete storage, imperfect quality control and misunderstanding. As a result, there are big flaws in the use of medical records as evidence, seriously affecting the capacity of medical institutions to provide evidence. Therefore, it is necessary to strictly write, keep and supervise medical records so as to ensure the truthfulness and objectivity of the medical records and raise the legal awareness of medical staff so as to enhance the evidential value of medical records.