Do not transcribe the case history afterwards and have evidence effectivenesses

Do not transcribe the case history afterwards and have evidence effectivenesses
The intersection of will and hardworking some the intersection of county and hospital Liu take to the court with one infant death. The hospital finds while prepared and should be told the case history is lost, transcribe a case history to the court again. Having dialed three to examine in lawsuit, the hospital loses a lawsuit because of can't put to the proofing. Does not the case history transcribed accurately have law that prove strength? The expert reminds, in the case is tried, the objective fact does not totally equate with the juristic fact. The brief introduction hospital of the details of the case loses a lawsuit in autumn of 2005 because the case history is transcribed, some pediatrics of saving the hospital of a county accepted one for medical treatment " in heart failure that acute bronchus pneumonia was amalgamated " Infant,medical personnel pass by 20 rescue of over hour,disappear to take a favorable turn to aggravate instead with condition infant, then the doctor proposes transferring the infant to the hospital of higher level to further treat and cure. After the infant transfers to the city hospital, pass all rescue measures proved ineffectual to die after four days. After infant's death, his father finds the county hospital and demands to copy the case history, but doctors on duty can not find the infant's case history. After the doctor confirmed the case history is lost, " the infant has been in our academy for less than 24 hours of hospital stays after writing one to the infant's father, so the case history has not filed to keep " Identification. Later, suffered from the direction court and litigated, thought it caused infant's death that the fault exists in the medical behavior, require the hospital to compensate. When the hospital is preparing and should be sueing, find infant's primitive case history materials are lost, the ones that transcribe to the infant the case history again are in hospital, refer to the court together with primitive prescription,etc.. The court, through trying, by " can't put to the proof " Decide against county hospital. The county hospital refuses to obey and adjudiacates in the first instance that puts forward appeal, the judgement result of the second instance court is to " rejects the appeal, uphold decision " . The county hospital thinks the second instance court is still inequitable in judgement, then engage the lawyer to appeal to people's fundamental laws and principles working committee separately again, submits the procuratorate to and protests, put forward the application that is reviewed to higher court in the province at the same time. But this case still loses a lawsuit and ends with the hospital finally. As to the judgement of this case, I think the judgement that the court pervert the law, but legal judgement, need medical worker to strengthen the understanding of relevant law, the medical behavior of norm abiding by laws from it, ensure medical security and doctors and patients' legitimate rights and interests of both sides better. Do not have evidence effectiveness to transcribe the case history afterwards " whether the Supreme People's Court about civil several regulation of Evidence in Litigation " article 4 ' Eight) The fund stipulates: "Infringement lawsuit caused by medical behavior, sought medical advice by the medical organization and treated the behavior with there is no causality and not have medical fault that undertake the burden of proof while damaging the results. " Its article 2 still stipulates: "It is not enough to prove the party's fact is advocated that there is no evidence or evidence, the party shouldering the responsibility of putting to the proof undertakes the unfavorable consequence. " These regulations require, in the medical compensation for damage is appealed, the medical organization must put out the legal, true evidence with relation, to prove there is not fault in the medical behavior, or even the medical behavior has fault, its behavior of fault has no causality with the patient's damage consequence. Otherwise, the medical organization will bear " can't put to the proof " Legal liability. In this case, because " proves " which doctors on duty wrote to the plaintiff Have proved the primitive case history materials have already been lost, though doctor's order and primitive prescription transcribed again are totally identical, but is not recorded by primitive condition, the court asserts there is not evidence effectiveness in this case history transcribed, therefore judge the hospital can't put to the proof. This draws legitimacy of the evidence, is also called the law question of the evidence. It is generally acknowledged, the legitimacy of the evidence means the evidence conforms with the legal provision from form and source, there is not a reason characteristic that can't be adopted. In the current law of our country, the law of the evidence, is mainly shown as the evidence must have form of the legal provision and be collected, investigated and verified and used according to the legal procedure by legal personnel. The case history is a kind of important legal evidence, its law is taking according to issuing and implementation of Ministry of Public Health <>With " case history regulation of medical organization ", case history materials serve as evidence, must guarantee, write qualification of personnel legal writing time limit to be legal keeping management to be legal also. In this case, because the county hospital has not kept the case history properly, loses the primitive case history materials, and before telling, doctors had already informed infant's father about " the case history did not file to keep " in written form . This indicates the hospital is used in the case history that should be told, does not finish within legal time, can't be satisfied naturally" Legal personnel, legal procedure " Law require can't regard as by evidence whether it last letter. The supreme realm that try is to " bases on fact that the objective fact does not mean the administration of justice of juristic fact, take the law as criterion " . But this one " The fact " It is not the objective, overall, absolute fact, do not " return the true colours of the things " Fact,but plant juristic fact. Look from economics and different angles of law sociology between jurisprudence, law philosophy, law, the lawsuit hopes what pursued is an objective fact, but that got is a juristic fact. But existing truth of the matter of understanding that the objective fact refers to not to rely on people. The objective fact is in the philosophical meaning, but its detached understanding of people exists independently, no matter whether people can know and prove it, it exists objectively. And the juristic fact refers to according to legal procedure, case fact proved by the legal evidence. This too says, fact that the evidence supports is a juristic fact. The forming of the juristic fact must accord with the form of the legal provision and limited by appraising in the law, the evidence that and the court adopts the letter must be the juristic fact. In the realistic lawsuit moves about, the juristic fact nearly equates with the objective fact sometimes, but totally run counter to the objective fact sometimes. Because of this case, the objective fact is that the medical worker on duty fulfils one's duty to treat and cure, and escort infants to change over to the city hospital in the whole journey after making the night shift and already fulfil the legal obligation of making a diagnosis, pay attention to the obligation and obligation of changing the place of examination. However, are lost because of the primitive case history materials and show and give the plaintiff square " proved " before the case history entered contentious procedure, transcribed again is told by the doctor on duty Having denied, so, the objective fact can't become the juristic fact, namely the hospital can't prove there is not medical fault in the medical behavior, can't prove either the infant's death is based on its serious condition, but not the hospital delays making a diagnosis or due to wrong treatment. The lesson that this case should be drawn, through this case, the medical worker should establish such consciousness, namely the case history, as the evidence, it must be within legal time limit, the personnel with legal qualification write the original paper finished and kept properly. " legal time limit " It is according to Ministry of Public Health <>Regulation last case history to write,if not for the first time course of disease record must finish in admitted to hospitalling eight hour, great medical history must finish in admitted to hospitalling 24 hours, endanger Serious condition tell, must finish at once, operation, and anaesthesia tell signing must be finished in front of skill, the intersection of course of disease and record must finish at once while being postoperative, surgery record must be finished within postoperative 24 hours, rescue, record, must finish afterthought factually in the 6 hour and mark out afterthought time wait for in rescue. If the case history is recorded and has not finished within legal time limit, once the medical dispute takes place, various records especially written troactively after the case history is sealed up for safekeeping, will not have legitimacy when using as the evidence. " personnel who have legal qualification " Mean the record of course of disease must be written by the registered medical practitioner for the first time, the doctor's order must be signed by the registered medical practitioner, the doctors of higher authorities must have signatures of doctors of higher authorities to record to make the rounds of the wards, the operation record must be written or revised and signs etc. by operator and doctor. Otherwise, the persons who write will not accord with " legal qualification " Requirement,case history as evidence either have legitimacy. It is the basic demand of every medical worker of current society to practise medicine in accordance with the law, this needs medical worker to finish various case history records on time, the doctors of higher authorities should revise the record that the intern or subordinate doctor wrote and sign in time, solidify the objective fact as the juristic fact in time, in order to protect medical worker's own legitimate rights and interests. Hospital administrative department want, improve case history, manage constantly, guarantee every in hospital the intersection of case history and materials of patient file and keep for a long time in time. In addition should define the content authority that a medical worker provides a certificate, and strengthen management, avoid the phenomenon which is similar to this case takes place. (Author's unit: Central hospital of Taizhou of Zhejiang Province)

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