刘 鑫^1，2，3

1.“2011 计划”司法文明协同创新中心（中国政法大学），100088 ；2.证据科学教育部重点实验室 （中国政法大学），100088 ；3.中国政法大学医药法律与伦理研究中心，100088

【摘 要】由于病历在医疗纠纷处理中具有核心证据价值，因而在医疗纠纷愈演愈烈的大背景下，医患双方对病历的证据效力的争执也变得日益复杂。由于法律专业人士不具有医学专业知识，因而对病历的真伪及证据价值的判断显得无能为力，为了正确判断病历的证据价值，为了更好地使用病历作为认定案件事实的依据，因而迫切需要启动病历法律评估。病历法律评价应当坚持全面性、整体性、规范性和不苛求的原则，由有相关专业知识和背景的专业人士依照法定程序，采用专业评估方法，对病历的完整性、规范性和客观性进行评价，并提出专业性的评估意见。

【关键词】病历；病案；证据；法律评估；医疗纠纷

【中图分类号】D915.13

【文献标识码】A

【文章编号】1674-1226（2014）03-0325-21

Study on legal assessment of medical record. Liu Xin^1，2，3. 1. Collaborative Innovation Center of Judicial Civilization, Beijing, 100088; 2. Key Laboratory for Evidence Science (China University of Political Science and Law), Ministry of Education, Beijing, 100088; 3. Center for Health and Pharmaceutical Law and Ethics, China University of Political Science and Law, Beijing, 100088

【Abstract】Since medical record has core evidentiary value in medical disputes, tensions between doctor and patient on evidentiary effectiveness of medical record has become increasingly complex, within the overall context of intensified doctor-patient disputes. Due to legal professionals’ lack of medical expertise,they are incapable to assess the authenticity and evidential value of medical record. Thus, in order to correctly determine the evidential value of medical record and for better use of medical record as the basis in case fact-finding, it is urgent to initiate legal assessment of medical record. Such assessment work shall adhere to the principles of comprehension, integration, standardization and no-demanding, conducted by experts with relevant professional knowledge and background following due course of law, with professional assessment method, focusing on the integrity, standardization and objectiveness of medical record, and finally generate professional assessment.

【Key Words】Medical record, Archives of medical record, Evidence, Legal assessment, Medical dispute