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自2002年9月1日国务院颁布《医疗事故处理条例》以及《最高人民法院关于民事诉讼证据的若干规定》对医疗行为引起的侵权诉讼实行了“举证责任倒置”的背景下,临床医务人员如何将医疗行为的原始证据完整、真实和客观地保留下来,显得尤为重要[1]。为此,卫生部、辽宁省卫生厅在2002年相继出台了“病历书写基本规范(试行)”(以下简称“规范”)、护理病历书写要求及质量标准(以下简称“标准”),规范医疗文件书写,力求真实、客观、准确、及时反映患者在接受治疗护理过程中的全貌,使医疗护理文件成为医疗机构的重要举证材料,使其具有法律效应。目前,此项工作已经得到各级医院及护理人员广泛重视与认同。
Since September 1, 2002, the State Council promulgated the “Medical Accident Handling Regulations” and “Several Provisions of the Supreme People’s Court on Civil Litigation Evidence,” in the context of the implementation of the “inversion of burden of proof” on infringement lawsuits caused by medical actions, how do clinical medical personnel perform? It is particularly important to preserve the original evidence of medical behavior in a complete, true and objective manner [1]. To this end, the Ministry of Health and the Liaoning Provincial Department of Health issued in 2002 the “Basic Rules for Medical Record Writing (Trial)” (hereinafter referred to as “the Code”), written requirements and quality standards for nursing records (hereinafter referred to as “standards”), and standardized medical treatment. Document writing, strive to be truthful, objective, accurate and timely to reflect the patient’s overall picture in the process of receiving care and treatment, so that medical care documents become important proof materials for medical institutions, making it a legal effect. At present, this work has received extensive attention and recognition from hospitals and nursing staff at all levels.