論醫事人員於醫療爭議時應否進行病歷的修正或補述

病歷是法律上為執行醫療業務所製作之文書，醫事人員以此記錄病患在就醫過程所接受的醫療照護；然目前臺灣醫療的現況，醫護人力短缺、過多的病人量以及繁重的醫療業務，讓醫事人員在第一時間先忙於投入病患的救治，而後才憑藉著記憶書寫下病歷，因此，僅能擇要書寫紀錄。然一旦醫療爭議事件發生，醫事人員回頭檢視病歷，可能因為病歷記載過於簡潔無法呈現醫療實況，而面臨是否要進行補述或修正的掙扎，又因臨訟時病歷的補述或修改，普遍不為法院所採信；在如此兩難的情況下，本文嘗試從臨床醫療實況與法院審判實務中找出平衡，建議在電子病歷中規劃補述之欄位，期能讓醫事人員即便係為事後補述，亦能如實呈現醫療照護過程。

關鍵字

病歷修正；舉證責任；醫療爭議

並列摘要

Medical records are legal documents produced in medical practice, in which medical personnel record the health care received by patients when seeking medical treatment. However, in the current healthcare environment in Taiwan, medical staff are busy saving and treating patients at the first moment and completing medical records by memory after the diagnosis and treatment medical staff due to the lack of human power, patient overflow, and heavy medical business. As a result, only brief contents are recorded. In the unfortunate event of a medical dispute, medical personnel may struggle to amend or supplement the contents, which are often not admissible by the court when the medical records do not fully present all medical facts. This paper attempts to find a balance between the dilemma of actual clinical condition and court practice and proposes the implementation of a supplementary comment area in electronic medical records, thus allowing the medical personnel to amend the records and reveal the medical care processes.

並列關鍵字

medical record ； burden of proof ； medical dispute

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