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医疗机构负有病历记载或保存义务,该义务的内容包括义务目的、记载内容及记载程度三个方面,该义务常见的诉讼实现路径是证据保全和文书提出制度。违反病历记载或保存义务的证明妨碍的构成要件有五个,其法律效果主要是医疗过错证明责任的减轻,包括证明责任的转换、事实推定、证明标准的降低,具体由法官根据实际情况决定,仅在证明妨碍行为构成重大医疗瑕疵时始得减轻因果关系的证明责任。我国法律关于病历记载或保存义务的规定较为细致且大致合理,但就违反该义务的证明妨碍的规定仍存在一些缺陷。
The medical institutions shall bear the record-keeping or preservation obligations of the medical records. The obligations include the purpose of the obligation, the content of the record and the extent of the record. The common route for the realization of the obligation is the system of evidence preservation and the filing of documents. There are five constitutional impediments to the identification of medical records that violate the records or preservation obligations, and the legal effects are mainly the reduction of the burden of proof of medical malpractice, including the conversion of burden of proof, de facto estimation and the lowering of the standard of proof, which is decided by the judge according to the actual situation, It is only the burden of proof that alleviates causation if the obstruction of conduct constitutes a significant medical defect. The provisions of our law on medical record keeping or preservation obligations are more detailed and generally reasonable. However, there are still some shortcomings in the regulations that obstruct the proof of breach of the obligation.