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病案是最基础的医疗信息资料的汇集,它的价值,除了在医教研中发挥广泛作用外,另一重要价值,就是在医疗事故、法律诉讼中的法定证据作用。病案与医疗事故的联系,许多医务人员还没有从法律的高度加以认识和重视。本文拟对此进行讨论并略陈管见。病案与医疗事故关系的基本认识病案与医疗事故的联系,最明白不过地反映在国务院《医疗事故处理办法(1987年)》中(以下简称《办法》)。《办法》第八条规定:“发生医疗事故或事件的医疗单位,应指派专人妥善保管有关的各种原始资料,严禁涂改、伪造、隐匿、销毁。”这里所指的各种原始资料,主要是指病案,第十四条规定了医疗事故鉴定委员会对病案等资料的审阅、要求、查证。第二十三条则规定了发生医疗事故或事件后,丢、涂、匿、伪、毁病案的处理。这些规定,足以说明在发生医疗事故后,病案所具有的法律地位,以及在处理医疗事故过程中的重要性。但是,在医疗实践中,特别是在遇到医疗纠纷及医疗事故时,涂、匿、伪、毁、病案的现象仍时有发生,其后果,一方面扰乱了医疗纠纷的解
The medical record is the most basic collection of medical information. Its value, in addition to its extensive role in medical education and research, is another important value, which is the role of statutory evidence in medical accidents and legal proceedings. The link between medical records and medical accidents, many medical personnel have not yet recognized and valued from the height of the law. This article intends to discuss this and take a brief look at it. The basic understanding of the relationship between medical records and medical malpractices The connection between medical records and medical malpractices is most clearly reflected in the “Measures for handling medical malpractices (1987)” of the State Council (hereinafter referred to as the “Measures”). Article 8 of the Measures stipulates that: “In the case of a medical unit where a medical accident or event occurs, special personnel should be assigned to properly maintain all kinds of original data, and alteration, forgery, concealment, and destruction are strictly prohibited.” It mainly refers to medical records. Article 14 provides that the medical accident appraisal committee reviews, requests and verifies medical records and other data. Article 23 stipulates the handling of cases of losing, painting, hiding, falsifying or destroying medical records after a medical accident or event occurs. These regulations are sufficient to explain the legal status of the medical record after a medical accident and the importance of handling medical accidents. However, in medical practice, especially in the face of medical disputes and medical accidents, the phenomenon of smearing, concealing, falsifying, destroying, and medical records still occurs from time to time. The consequences, on the one hand, disrupt the solution to medical disputes.