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客观病历与主观病历对医疗纠纷的影响
引用本文:唐赛贞,张玉霞,方桂华.客观病历与主观病历对医疗纠纷的影响[J].中国病案,2009,10(11):20-20,19.
作者姓名:唐赛贞  张玉霞  方桂华
作者单位:福建省三明市第二医院,三明市,366000
摘    要:目的了解病历资料的分类和法律属性,正确区分客观病历与主观病历的复印范围。方法按照《医疗事故处理条例》和《医疗机构病历管理规定》的有关内容进行分析。结果病历资料的缺陷和复印病历权限对医疗纠纷产生一定的影响。结论提高医患双方对客观病历与主观病历的分类意义和法律属性的重要性的认识,避免产生医疗纠纷。

关 键 词:客观病历  主观病历  医疗纠纷

Brief Analysis of the Influences of Objective Medical Records and Subjective Medical Records on Medical Disputes
Tang Saizhen,Zhang Yuxia,Fang Guihua.Brief Analysis of the Influences of Objective Medical Records and Subjective Medical Records on Medical Disputes[J].Chinese Medical Record,2009,10(11):20-20,19.
Authors:Tang Saizhen  Zhang Yuxia  Fang Guihua
Institution:( The Second Hospital of Sanming city, special base of clinical teaching of Fujian Medical University Fujian 36600 )
Abstract:Objective To investigate the classification and legal nature of medical records data, and correctly distinguish the copy range of objective medical records and subjective medical records. Methods Analysis was done based on the relevant contents of The Regulation on the Handling of Medical Accidents and The Regulation on Medical Records Management of Medical Institution. Results The defects of medical records data and copy authority of medical records produced some influences on medical disputes. Conclusion Tile understanding of doctors and patients on the taxonomic significance and legal nature of objective medical records and subjective medical records should beimproved to avoid medical disputes.
Keywords:objective medical records  subjective medical records  medical dispute
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