CAJ | 학술논문

病案作为医疗诉讼中重要的证据材料,能对诉讼的处理及结果产生重要影响.通过回顾1例异位甲状腺案例治疗及庭审经过中的关键环节,梳理相关病历资料中关于临床诊断及病理诊断的记录,并查阅现有学术文献,结合“下颌下区”的解剖学描述和“颌下肿物”的疾病诊断名称与分类,讨论分析本案中病历记录的证据作用及其对诉讼结果的影响.
병안작위의료소송중중요적증거재료,능대소송적처리급결과산생중요영향.통과회고1례이위갑상선안례치료급정심경과중적관건배절,소리상관병력자료중관우림상진단급병리진단적기록,병사열현유학술문헌,결합“하합하구”적해부학묘술화“합하종물”적질병진단명칭여분류,토론분석본안중병력기록적증거작용급기대소송결과적영향.
As important evidence materials in medical litigation ,medical record can have a big effect on the disposal and result of the lawsuit .By a retrospective analysis on the treatment of a case of ectopic thyriod and the key links in the process ,discuss the records which related clinical diagnosis and pathological diagnosis in the medical record materials ,along with available academic refer -ences ,combine with the anatomy description of “region under lower jaw” and the classification as well as diagnosis definition of “lump under the jaw” ,we investigate the evidence role of medical record and its effect on the consequence in this litigation .