论文部分内容阅读
卫生部《病历书写基本规范》规定,病历应当书写工整,字迹清楚,表达准确,语句通顺,标点正确。书写过程中出现错字时,应当用双线画在错字上,不得采用刮、粘、涂等方法掩盖或去除原来的字迹。然而,现实是这个规定如同废纸,遇到不执行的也无法处罚,因缺乏相关法律支撑,通常医患纠纷只有造成人身伤害及经济损失后,法院才会受理案件；而对于医疗事故以外的原因引起的其他医疗纠纷,相关法律并无明确规定。结果,医生写的“天书”病历比比皆是。南京一患者因看不懂医生开出的病历内容,将诊治医院告上法庭,要求对方“重写病历”,这在江苏乃至全国都是首次。南京市鼓楼区法院近日将对这起“天书病历”案宣判。
The Ministry of Health’s “Basic Rules for Writing Medical Records” stipulates that medical records should be written neatly, clearly written, accurately expressed, fluent in sentences, and correct in punctuation. In case of typos in the process of writing, double lines shall be used to draw typos, and scraping, sticking or painting shall not be used to conceal or remove the original handwriting. However, the reality is that this provision is like waste paper, and cannot be punished if it is not implemented. Due to the lack of relevant legal support, usually the doctor-patient dispute only causes personal injury and economic loss, the court will accept the case; and for medical accidents other than For other medical disputes caused by the reason, there is no clear provision in the relevant laws. As a result, medical records written by doctors abound. A patient in Nanjing could not understand the contents of the medical records issued by doctors, and he went to court to ask him to “rewrite medical records”. This was the first time in Jiangsu and even in the whole country. The Drum Tower District Court of Nanjing City has recently pronounced the case on the “Birthday Medical Record” case.