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篇名
【醫療刑事法】急診腦出血案:病歷是證據之王嗎?
並列篇名
Criminal Law in Medical Malpractice: brain hemorrhage in Emergency Station: Is the Medical Record the Queen of Evidence?
作者 林萍章王俊彥
中文摘要 被害人X因摔車造成頭部、臉部與手腳擦傷,被告醫師Y以X手腳活動與言談正常逕認其意識清楚,而未進行神經學檢查,後由護士交付其友人應注意事項之書面指示並予以說明,即讓X出院。X後因頭部撞擊造成出血、昏迷,被發現死於租屋處。本案經數次鑑定並纏訟多年,法院最後認為X於就診時之GCS昏迷指數為15分,無進行X光或電腦斷層掃描之必要,且Y之處置並未違反醫療常規而無過失。
事實上地區或基層院所之病歷記載多不詳盡,本件被告Y因神智欄記載「清楚」,即認無須於神經檢查欄再填寫,此為基層醫療之通病;然而病歷係醫療訴訟中極重要之文書證據,倘若本件確實記載神經學檢查的每一項目,法院採信的機率極高。從此來看,病歷確實為證據之王。
英文摘要 The victim X has injured in his head, face, hand and foot. The physician Y as an accused didn’t take a neurological examination to the X, because X’s physical movements and speaking were normal, and had a clear consciousness as a result. The X was discharged after the nurse gave precautions in writing to his friends. However, the X was dead in his place because of cerebral hemorrhage and coma, which were caused by the hit. This case was litigated and identified for serval years. The court deemed finally that the X’s Glasgow Coma Scale (GCS) was 15 and there was no necessary to take an X-ray or a CT-Scan for the X. What the Y did, doesn’t again the medical rules and had consequently no fault.
Actually, local hospitals don’t record detailed. The Y in this case didn’t record the result of the neurological examination because the Y’s consciousness was recorded as clearness. It is a common falling in clinic medicine. Nevertheless, the medical records are very important evidence in medical litigations and have a high degree of proof, if each part of the neurological examination was filled in certainly. The medical record is in conclusion the queen of evidence.
起訖頁 078-118
關鍵詞 外傷性腦出血昏迷指數急診醫療常規病歷醫療水準罪疑惟輕
刊名 月旦醫事法報告
出版單位 元照出版公司
期數 201701 (3期)
DOI 10.3966/241553062017010003006  複製DOI  DOI申請
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