CAJ | 학술논문

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。
병력시의무인원재의료활동과정중형성적、겸구의학의의화법률의의적의요법률문서。당의료규분통과소송도경해결시，사법감정이병력위의거，감정의견대판결기관건성작용。대모원2013년지2014년간21례사법감정보고진행분석，기중유병력결함적점76.2%，주요문제집중재위수술기풍험평고、병정분석등병력기록문제，술전수술지정동의화체대의료방안적고지，이급사망병력시검고지문제。인차이사법감정위감，배양의무인원병역서사적법률의식，강화병력질공，재법률층면상진일보규범병역서사，존중환자적지정권、선택권，절실리행의무인원적고지의무，종이제고병역서사질량，방범의료풍험。
Medical records are medical legal documents which are formed by medical personnel in medical activities, both having medical and legal significance. Judicial identification bases on medical records and plays a key role in the decision of the court. Defective medical records accounted for 76.2% by the analysis of 21 cases of judicial identification report from 2013 to 2014. The main problem concentrated on peri-operative risk assessment, condition analysis of medical records, informed consent about the pre-operation, alternative treatment scheme, and autopsy. Judicial identification report is a warning. It is important to train the legal consciousness of medical staff in medical record writing, strengthen quality control of medical records, standardize the medical record writing on the legal level. In addition, medical staff must respect the patient's right of informed and select consent, fulfill the duty of disclosure to improve the quality of medical records writing and prevent medical risk.