摘要
理記錄是護理人員在執業過程中所做的例行性的業務文書，其反映護理品質，也是醫療糾紛發生時具證據能力的重要書證。護理人員執行業務時應製作清晰、詳實、和完整的記錄，這是法律上的規定，也是護理人員保護自己的方法之一。記錄本身是否能完整地呈現護理過程及記錄中所呈現的護理過程是否正確，是二項在書證上極為重要的要素，然臨床上因種種原因，護理人員書寫的記錄有時不完整或不正確。本文闡述醫療糾紛發生時之法律責任，過失責任要件及過失判斷基準，證據方法及能力等方面，進一步討論護理記錄之法律功能，以及如何使護理記錄能成為具有保護能力的重要證據。企能提升護理人員法律智能，使其認知護理記錄在訴訟時舉證責任中如何被具體運用，進而提高其對書寫記錄的重視及意願，使護理記錄成為醫療糾紛發生時真正足以證明護理人員無過失，保護護理人員的重要證據。
並列摘要
Nursing records are the routine business documents maintained by nurses during daily practice. They reflect the quality of care and serve as important documentary evidence when medical disputes occur. Nurses should make clear, detailed and complete records of nursing practice as it is not only required by law but also a method of self-protection. Whether the nursing records can present the complete nursing process and whether the nursing processes entered in the records are correct are two important elements of documentary evidence. Nursing records kept by nurses are however sometimes incomplete or inaccurate due to various reasons. This article describes the legal liabilities when medical dispute occurs, elements of negligence and the determination criteria, rules of evidence and burden of proof, then explores the legal function of nursing records and how to ensure they can serve as important evidence for protective purposes. Hopefully, this will help nurses improve their legal knowledge, make them aware of how nursing records are used with regards to burden of proof in lawsuits, and to increase their emphasis and willingness to maintain nursing records. Nursing records can then serve as important evidence to prove nurses' innocence and provide them with protection.
參考文獻
被引用紀錄
延伸閱讀
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