应用《侵权责任法》规范病案管理的责任与风险(1)
[摘要]随着社会的发展，人们法律意识不断提高，特别是《侵权责任法》出台后，医疗机构成为被告的情形已是常态，除诊疗行为侵权外，因病案管理工作不当而导致侵权的情形也时有发生，如在病案形成的真实性、保管的时效性、利用的合法性及病案隐私保护方面均有涉及，这让医疗机构的管理者更为困惑。本文简述了《侵权责任法》与病案管理相关的法律条文，结合近年来我院在病案管理过程中所涉及与侵权行为有关的案例，分析表明医疗机构在依法管理方面有了很大的进步和规范，但因部分医务人员不够重视病案管理工作，而导致医疗机构在病案管理的过程中出现了一些侵权的行为，让医疗机构潜在一定的风险。因此应用《侵权责任法》规范病案管理，可以让医疗机构的管理工作更加合法和规范，能不断提升医疗机构的综合管理水平，而保护了医患双方的合法权益，这在整个医疗系统中是值得推广使用的。
[关键词]侵权责任法；病案管理；责任；风险
[中图分类号] R197.3 [文献标识码] A [文章编号] 1674-4721(2018)5(c)-0133-04
Application of Tort Liability Law in standardization of the responsibility and risk of medical record management
LIU Hong-wei LIAO Yu-hong LIAO Hong-xia
Department of Medical Affairs，Heyuan Hospital of Traditional Chinese Medicine，Guangdong Province，Heyuan 517000，China
[Abstract]With the social development，people′s legal consciousness has been constantly improved，especially after the introduction of Tort Liability Law.The situation of a medical institution as a defendant has become a norm.In addition to the tort of diagnosis and treatment behavior，the cases of infringement caused by mismanagement of medical records also occur，such as the authenticity in the forming of medical records，the timeliness in preservation，legitimacy in usage and privacy protection of medical records，which makes the management of medical institutions more confused.This paper describes the relevant legal provisions of Tort Liability Law about medical record management，combined with related tort cases in our hospital in recent years in the medical record management process，analyzes and indicates the great progress and standardization of medical institutions in management in accordance with the law.However，part of the medical staff do not pay enough attention to the management of medical records，resulting in infringement behavior of medical institutions in the medical record management process，which makes medical institutions confronted with potential risks.With the application of Tort Liability Law in regulation of medical record management，medical institutions can make the management work more legitimate and standardized and improve the comprehensive management level，so as to protect the lawful rights and interests of both doctors and patients，which is worthy of promotion in the whole medical system.
[Key words]Tort Liability Law；Medical record management；Responsibility；Risk
《中華人民共和国侵权责任法》(以下简称《侵权责任法》)是为了保护民事主体的合法权益，明确侵权责任，预防并制裁侵权行为，促进社会和谐稳定，而制定的一部法律。该法共对七种侵权行为进行了规定，其中第七章把医疗损害责任以独立的篇章明确出来，在此之前对医疗损害处理的主要依据是《医疗事故处理条例》，而现在《侵权责任法》则把医疗侵权的情形及归责原则以法律的形式充分给予明确[1]。该法自实施以来，对医疗机构的管理方式及医疗行为的法律责任带来了明显的变化和影响，本法第七章关于医疗损害的法条共有11条，其中有3条都直接涉及到病案管理的工作，由此可见医疗机构在病案管理过程中的法律责任与风险地位日渐突出，因此对病案进行依法规范性管理就势在必行了。, http://www.100md.com(刘洪伟 廖宇红 廖红霞)
[关键词]侵权责任法；病案管理；责任；风险
[中图分类号] R197.3 [文献标识码] A [文章编号] 1674-4721(2018)5(c)-0133-04
Application of Tort Liability Law in standardization of the responsibility and risk of medical record management
LIU Hong-wei LIAO Yu-hong LIAO Hong-xia
Department of Medical Affairs，Heyuan Hospital of Traditional Chinese Medicine，Guangdong Province，Heyuan 517000，China
[Abstract]With the social development，people′s legal consciousness has been constantly improved，especially after the introduction of Tort Liability Law.The situation of a medical institution as a defendant has become a norm.In addition to the tort of diagnosis and treatment behavior，the cases of infringement caused by mismanagement of medical records also occur，such as the authenticity in the forming of medical records，the timeliness in preservation，legitimacy in usage and privacy protection of medical records，which makes the management of medical institutions more confused.This paper describes the relevant legal provisions of Tort Liability Law about medical record management，combined with related tort cases in our hospital in recent years in the medical record management process，analyzes and indicates the great progress and standardization of medical institutions in management in accordance with the law.However，part of the medical staff do not pay enough attention to the management of medical records，resulting in infringement behavior of medical institutions in the medical record management process，which makes medical institutions confronted with potential risks.With the application of Tort Liability Law in regulation of medical record management，medical institutions can make the management work more legitimate and standardized and improve the comprehensive management level，so as to protect the lawful rights and interests of both doctors and patients，which is worthy of promotion in the whole medical system.
[Key words]Tort Liability Law；Medical record management；Responsibility；Risk
《中華人民共和国侵权责任法》(以下简称《侵权责任法》)是为了保护民事主体的合法权益，明确侵权责任，预防并制裁侵权行为，促进社会和谐稳定，而制定的一部法律。该法共对七种侵权行为进行了规定，其中第七章把医疗损害责任以独立的篇章明确出来，在此之前对医疗损害处理的主要依据是《医疗事故处理条例》，而现在《侵权责任法》则把医疗侵权的情形及归责原则以法律的形式充分给予明确[1]。该法自实施以来，对医疗机构的管理方式及医疗行为的法律责任带来了明显的变化和影响，本法第七章关于医疗损害的法条共有11条，其中有3条都直接涉及到病案管理的工作，由此可见医疗机构在病案管理过程中的法律责任与风险地位日渐突出，因此对病案进行依法规范性管理就势在必行了。, http://www.100md.com(刘洪伟 廖宇红 廖红霞)