Abstract

AbstractMedical records are objective and real diagnostic and treatment records formed in the process of medical practice, which play an important role as written evidence and original evidence in medical malpractice assessment and medical dispute litigation. However, some problems such as untrue records, incomplete storage, imperfect quality control and improper understanding, exist in practice. As a result, medical records as evidence have many defects and seriously affect the proof capability of medical institutions. Therefore, it is necessary to strictly control medical record writing, storage and monitoring, so as to ensure the reality and objectiveness of the medical records, improve the legal awareness of medical staff and enhance the evidential value of medical records.

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