医疗纠纷处理新规背景下病历真实性的保障与认定

刘 鑫^1，2，3  赵彩飞⁴

（1．中国政法大学 证据科学教育部重点实验室，北京 100088；2．中国政法大学 “2011”司法文明协同创新中心，北京 100088；3．中国政法大学医药法律与伦理研究中心， 北京 100088；4. 中国政法大学法律硕士学院，北京 100088）

【摘 要】病历从最开始的医学需求，逐渐发展到科研教学、保险理赔、法律诉讼等的需求，病历的真实性是满足这些需求的首先且重要的条件。因此如何保障病历的真实性、在病历真实性受到质疑时如 何进行认定就成为至关重要的问题。近年来颁布的，涉及病历内容的行政法规、部门规章均对病历真实 性提出了要求，并且有许多保障病历真实性的规定。病历真实性认定的司法实践也在逐渐转变态度，并且有相关的司法解释、会议纪要公布来指导法官进行病历真实性的认定。即使，病历真实性的保障和认定有了一些发展和完善，但是我国的病历真实性保障还是存在着基础性保障不完善、重要保障措施—病历封存随时受到质疑等问题；病历真实性认定还存在着认定主体不清、认定标准模糊的问题。本文首先分析了这些问题，之后从卫生行政部门、医疗机构、法官和立法的角度提出完善的建议。

【关键词】病历；病历真实性；保障；认定 ; 病历封存

【中图分类号】D915.13

【文献标识码】A

【文章编号】1674-1226（2018）04-0453-16

Guarantee and identification of the authenticity of medical records in the context of new regulations for medical disputes. Liu Xin1,2,3, Zhao Caifei4

(1.Key Laboratory of Evidence Science (CUPL), Ministry of Education, Beijing 100088, China; 2. "2011 Plan"-Collaborative Innovation Center of Judicial Civilization (CUPL), Beijing 100088, China; 3.Center for Health and Pharmaceutical Law and Ethics of China University of Political Science and Law (CUPL), Beijing 100088, China; 4.School of Juris Master of China University of Political Science and Law (CUPL), Beijing 100088, China).

【Abstract】The medical records, which initially was intended merely for medical needs, have gradually expanded its function to match up with the demand in research and teaching, insurance claims, legal proceedings,etc., in cases of which the authenticity of medical records has become a primary requirement. Therefore, it is crucial to guarantee the authenticity of medical records and to properly identify them when their authenticity is challenged. The administrative regulations and rules promulgated in recent years in China that concernmedical records have established requirements for the authenticity of medical records, specifying provisions to guarantee the authenticity of medical records. Concurrently, the judicial practice has been changing its stance towards identification of medical records, and related judicial interpretations and meeting minutes have been published to guide judges in identifying the authenticity of medical records. Notwithstanding the above mentioned developments and improvements in the guarantee and identification of the authenticity of medical records, the fundamental guarantee measures for the authenticity is nevertheless incomplete and, the sealing of medical records, as a key guarantee measure, is being constantly challenged, in addition to problems in undefined conductor for authenticity identification and ambiguous identification criteria. This article firstly analyzes the above mentioned issues, and then proposes to address these issues from perspectives of healthcare authorities,medical institutions, judges and legislation.

【Key Words】Medical records, Authenticity of medical records, Guarantee, Identification, Sealing of medical records