This study is a paper reviewed legal status of medical personnel and issues of law on recently discovered medical records. As the increase of medical personnel who have gone through the administrative disposal in regards to the medical records, it is needed to examine the legal issue or dispute on the medical records under the current law. Medical records are the statement on patient’s medical conditions made by the medical personnel. This records are used as important source for patient’s further treatment. This becomes the communication route between the patients and the other medical personnel, and it provides the patients a right to find out their medical information. According to the Medical Service Act (Article 21), a medical personnel shall prepare respectively a record book of medical examination and treatment. And medical personnel shall make a signature. Furthermore, the medical personnel or the opener of the medical institutions must preserve the record book (including an electronic medical record). Meanwhile, the issues of a ban on false entry, additional record, revision or manipulation on the medical record have been recently on the rise. This paper briefly examined the major issues in regards to the medical records. It especially clarified the legal duty on medical records and its major-contentious-issues. At the same time, it pointed out the problems of the unreasonable over interpretation of the law. Furthermore, this suggested the guidelines for the further discussion and review.
목차
I. 들어가는 말 II. 의무기록 관련 기본 내용 1. 의의 및 법적 성격 2. 소유권 III. 의무기록 작성 및 서명 의무 1. 의무기록 작성 의무 2. 의무기록 서명의무 IV. 의무기록 조작 금지 의무 1. 의의 2. 의무기록 조작행위 규제방안 V. 의무기록 보존 의무 1. 의무기록 보존의무 2. 의무기록 이관의무 VI. 맺음말 참고문헌 ABSTRACT
키워드
의무기록전자의무기록작성의무보관의무허위기재Medical recordsEMR(Electronic Medical Record)Duty to prepareDuty to preserveFalse entry
대한의료법학회는 “법학계, 법조계, 의료계가 공동하여 의료법학의 학제적 연구와 판례 평석 등을 통하여 전문분야에 있어서의 법률문화 향상에 기여함을 그 목적”으로 하여 1994년 2월에 태동한 이후 1999년 4월 24일에 공식 출범한 이래 2006년 3월 30일 법무부 산하의 사단법인으로 등록된 세계적 수준의 순수 학술단체이다.