一、病案书写质量与法律 近几年来,随着人们生活节奏的加快,公民法律意识的提高,法律民事纠纷不断增加,病案是法律鉴证的重要依据。在工作中,往往会遇到由于医生病历描述不清,诊断含糊,失去了鉴定价值,或者是无据可循。例如:我院曾接待一名法医做法律鉴定,由于病历中诊断鼓膜穿孔,未说明是陈旧性鼓膜穿孔,还是新鲜鼓膜穿孔,对病灶周围情况也未做描述,失去了鉴定价值,只能望文兴叹。 First, the writing quality of the case and the law In recent years, with the acceleration of people’s life rhythm, the increase of legal awareness of citizens, legal civil disputes continue to increase, medical records is an important basis for legal verification. At work, one often encounters unclear medical records, ambiguous diagnosis, lost appraisal value, or no evidence to follow. For example: Our hospital had received a forensic legal identification, due to the diagnosis of tympanic membrane perforation in the medical records, did not indicate the old tympanic membrane perforation, or fresh perforation of the tympanic membrane, did not describe the situation around the lesion, lost the identification value, can only hope Wen Xingtan.