诉讼实践视野下病历真实性的认定

在医疗损害纠纷诉讼实践中,经常发生由于医疗机构提供的病历存在真实性问题导致鉴定不能,最后被法院直接推定存在过错的情形。该文在诉讼实践视野下,通过分析病历出现真实性问题的原因,厘清病历瑕疵与真实性问题的区别,并建议从证据学角度进行严格审查或委托专业机构对病历真实性进行鉴定,但同时可能会增加诉讼的成本,耗费诉讼的时间,使医疗损害案件的审理更加复杂、漫长,甚至会继续激化医患矛盾。从长远看,就需要国家相关部门对医疗机构病历真实性制定统一的规范及认定标准,既做到专业、公平、合法,又能简化诉讼程序。

Identification of the Authenticity of Medical Records from the Perspective of Litigation Practice

In the practice of medical damage dispute litigation,it often occurs that the medical records provided by medical institutions have authenticity problems which lead to the failure of identification,and finally the court directly presumes that there is fault.From the perspective of litigation practice,this paper analyzes the causes of the authenticity problems of medical records,clarifies the differences between the defects of medical records and the authenticity problems,and suggests that we should learn from evidence.From the perspective of strict review or entrusting professional institutions to identify the authenticity of medical records,but at the same time,it may increase the cost of litigation,consume the time of litigation,make the trial of medical damage cases more complex and time consuming,and even continue to intensify the contradictions between doctors and patients.In the long run,it is necessary for the relevant departments of the state to formulate unified standards and recognition standards for the authenticity of medical records of medical institutions,which can not only be professional,fair and legal,but also simplify the proceedings.