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(영문) 대전지방법원 2016.05.26 2016고정229
의료법위반
Text

The defendant shall be innocent.

Reasons

1. The Defendant is an intention to operate a E member in Sejong Special Self-Governing CityD.

Each medical person shall keep a register of medical treatment and record the personal matters, such as the address, name, contact point, resident registration number, etc. of a person who has received medical treatment, the main symptoms, details of medical treatment,

However, on May 6, 2015, the Defendant: (a) on November 12, 2014, entered only F’s name and resident registration number in F’s medical record book with respect to F who received medical treatment at the above hospital; and (b) did not enter the remaining personal information therein; and (c) entered the medical record book with respect to total 291 persons who received medical treatment at the above hospital from November 12, 2014 to May 26, 2015, in addition to the name and resident registration number.

2. According to Article 22(1) of the Medical Service Act, a medical person shall keep records of each medical treatment record, assistance in child delivery record, nursing record, and other records of medical treatment, and shall record in detail the matters and opinions concerning the medical practice prescribed by Ordinance of the Ministry of Information and Communication, such as the principal symptoms, diagnosis and treatment of the patient, and the details thereof.

According to Article 14 (1) 1 of the Enforcement Rule of the Medical Service Act, matters to be recorded in the medical treatment register shall be recorded.

(a) Personal information, including address, name, contact information, resident registration number, etc. of a person who has received medical treatment;

(b) The main symptoms. In such cases, if it is deemed that a physician needs to do so, the medical history and family history associated with the main symptoms may be additionally recorded;

(c)

The diagnosis result or diagnosis name;

(d) The progress of the examination and treatment (for the outpatients, the symptoms, condition, and content of the treatment of the outpatients need to be recorded by the physician as the outpatients have changed.

only for patients recognized as such);

(e) Details of treatment (the treatment for injection, medication, treatment, etc.);

(f) the date and time of treatment;

When a doctor provides medical treatment for a patient, he/she shall prepare a record of medical treatment in which matters and opinions regarding the relevant medical practice are recorded and signed in detail pursuant to Article 22 (1) of the Medical Service Act.

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