杨天潼 王 旭

【摘 要】 临床病历资料中包含大量的、对诉讼有决定性影响的信息，因而对临床病历进行审查是医疗纠纷诉讼的基础。进行病历审查，需要具有医学思维和法学思维，鉴定人必须应用临床医学和法学的知识与经验才能完成病历审查。与此同时，鉴定人还必须能够区别哪些病历材料是可以粗略审查的，而哪些则是必须深入研究的。本文将介绍美国医疗过失索赔诉讼中的临床病历审查制度，主要包括两方面内容：一是确认病历审查的启动程序；二是掌握审查所需信息，并为确认潜在的医疗过失行为提供指导。

【关键词】 医疗过失；病历；司法鉴定；医疗诉讼；美国

【中图分类号】 D918.9

【文献标识码】 A

【文章编号】 1674-1226（2013）02-0215-14

Reviewing the Medical Record in American Medical Malpractice Claims. Yang Tiantong, Wang Xu. Lecturer of the Key Laboratory for Evidence Science，CUPL 100088.

【Abstract】 Medical records are the foundation of every medical malpractice claim investigation, which contains a great deal of information crucial to the investigation. Reviewing a medical record for claim investigation requires the development of a medical sense. That is, the investigator must apply clinical experience as well as concepts in law. Also required is the ability to differentiate between medical records that required only a cursory screening and those for which an in-depth review is necessary. The goal of this article is twofold: to instruct the investigator on how to determine when medical records require a review, and to explain how to extract the information needed to evaluate a case for potential liability.

【Key Words】 Medical malpractice, Medical record, Judicial authentication，Medical litigation, US