翟方明

【摘 要】 电子病历不是传统纸张病历的简单计算机化或电子化存储形式，而是医疗机构基于特定信息系统直接生成并反映患者诊疗过程中形成的所有资料的数字化信息集成。 它在功能上可以实现医疗信息的交换与共享，并辅助医生进行临床决策和提供公共卫生所需的信息再利用。电子病历符合证据合法性、关联性和真实性的要求，本身可以作为原始、直接证据适用。电子病历的真实性审查重点应该从可靠性和完整性两个方面进行。承认电子病历的证据法律地位并确立起符合我国国情的电子病历证据规则是电子病历推广应用的法律保障，也是当前医疗体制改革中一项紧迫要求。

【关键词】 电子病历；证据能力；证明力；运用规则；医疗纠纷

【中图分类号】 D915.13

【文献标识码】 A

【文章编号】 1674-1226（2013）02-0176-09

Discussion on the Application of the Electronic Medical Record Evidence. Zhai Fangming. Guangdong Medical College, Dongguan, Guangdong, 523808 China.

【Abstract】 Electronic medical record is not just the computerized or electronic form of the traditional paper-based medical records, but is a digitized information integration of reflecting all the information that formed in the process of treating a patient based on a specific computer system. It not only contributes to the exchange and share of medical information，but also assists doctor in making decision and provides the information for the Public Health. Electronic medical record can meet the requirements of evidence in terms of legitimacy, relevance and authenticity, so it can be applied as the original and direct evidence. Authenticity examination of electronic medical records should be focused on integrity and reliability. Recognizing the legal status of electronic medical records and establishing the rules of evidence suited to China' s conditions, is not only an important legal guarantee for promoting electronic medical record application, but also an urgent requirement of the current health care reform.

【Key Words】 Electronic medical records, Capability of evidence, Force of evidence, Application rules, Medical disputes