[1] Purport of the duty to prepare medical records under Article 21 (1) of the Medical Service Act

[2] Methods of preparing medical records

[3] The degree of detailedness in preparing medical records

[1] In a case where a doctor provides a patient with medical treatment, he/she shall prepare a medical record and signed a detailed statement of matters and opinions regarding the relevant medical treatment pursuant to Article 21(1) of the Medical Service Act, and a person who has not prepared a medical record shall be punished pursuant to Article 69 of the same Act. As such, the purport of allowing a doctor in charge of medical treatment to prepare a medical record is to make the patient himself/herself accurately recorded information about the patient's condition and the progress of the medical treatment and to make it available for the patient treatment continued thereafter, and to allow other employees in charge of medical treatment to provide such information with appropriate medical treatment and to use such information as data to determine the propriety of the relevant medical practice after the completion of the medical practice.

[2] Since there is no specific provision regarding the method of preparing medical records in the Medical Service Act, a doctor may prepare a medical record by the method of determining that it is effective in light of the content of medical practice and the progress of medical treatment. Therefore, a doctor may prepare a medical record by discretionary choice among the so-called problem-centered compulsory record preparation method, short-term compulsory record preparation method, and other methods, but the matters and opinions concerning medical treatment must be recorded in detail by any method.

[3] A medical doctor may use the patient's conditions and progress of medical treatment, etc. in the patient's continuous medical treatment, and provide other medical persons with appropriate information. After the completion of medical treatment, the doctor shall record in detail to the extent sufficient to determine the propriety of the medical treatment.

[1] Articles 21(1) and 69 of the Medical Service Act / [2] Article 21(1) of the Medical Service Act, Article 17 of the Enforcement Rule of the Medical Service Act / [3] Article 21(1) of the Medical Service Act, Article 17 of the Enforcement Rule of the Medical Service Act

[1] [2] Supreme Court Decision 97Do1234 delivered on August 29, 1997 (Gong1997Ha, 2987) / [1] Supreme Court Decision 97Do2156 delivered on November 14, 1997 (Gong1997Ha, 3916)

Defendant

Prosecutor

Attorney Gangwon-gu

Seoul District Court Decision 96No7073 delivered on July 9, 1997

The appeal is dismissed.

The grounds of appeal are examined.

1. In a case where a doctor provides a patient with medical treatment, he/she shall prepare a written record and signed with the matters and opinions regarding the relevant medical treatment in accordance with Article 21(1) of the Medical Service Act, and a person who has not prepared a medical examination and treatment shall be punished pursuant to Article 69 of the same Act. As such, the purport of allowing a doctor in charge of medical treatment to prepare a medical examination and treatment is to make the patient himself/herself accurately recorded without omitting any information about the patient's condition and the progress of the medical treatment and to allow the patient to use it for continuous patient treatment, as well as allowing other employees in charge of medical treatment to provide such information with appropriate medical treatment and to use it as data to determine the propriety of the relevant medical treatment after the completion of the medical treatment (see Supreme Court Decision 97Do1234, Aug. 29, 197).

However, there is no specific provision regarding the method of preparing medical records in the same Act. As such, a doctor can prepare medical records by means of determining that it is effective in light of the content of medical treatment and the progress of medical treatment. Therefore, a doctor can prepare medical records by discretionary choice among the so-called problem-centered compulsory records preparation method, short-term compulsory records preparation method, or other methods, but the matters and opinions concerning medical treatment must be recorded in detail by any method.

In addition, in light of the above purport, a doctor may use the patient's condition and progress of treatment, and his opinion in the patient's continuous treatment, and provide other medical persons with appropriate information. After the completion of the medical practice, the doctor shall record in detail to the extent sufficient to determine the appropriateness of the medical practice.

2. 원심판결과 원심이 유지한 제1심판결의 이유에 의하면, 제1심은, 피고인이 (가) 1995. 9. 25.부터 위 병원 101병동 21호실에 비호치킨성임파종, 회음부위 피부궤양 등의 질환으로 입원한 환자 양봉녀(여, 58세)의 주치의로서 위 환자의 치료를 담당하여 오던 중, 같은 달 28. 담당간호사들의 실수로 위 환자에 대한 항암치료제인 엠티엑스(MTX) 45㎎이 이중으로 투여되는 투약사고가 발생하였는데 그 후 위 환자에게서 별다른 이상 징후가 발생되지 아니하자, 위 환자의 단기의무기록지 결과란에 "간호사 착오로 3일째 엠티엑스 45㎎ 대신에 엠티엑스 90㎎ 투여되었음. 다음번 엠티엑스는 중단하기로 함"라고 기록하고, 위 단기의무기록지에 항문 부위의 피부궤양에 관한 그림을 그려 그 위치와 치료과정을 기록하고, 왼쪽 목 부분에 임파선이 커져 있어 이것도 그림으로 그려 이를 기록한 사실, (나) 또한 같은 해 11. 20. 같은 병원 125동 16호실에 비호치킨성임파종 환자로 항암요법치료를 위해 입원한 환자 이자우(여, 31세)의 주치의로서 위 환자의 치료를 담당하여 오던 중, 입원 당일 위 환자에게 아드리아마이신 60㎎을 5% 포도당 100㏄와 함께 투여하도록 예정되어 있었는데 담당간호사의 실수로 미톡싼트론 20㎎을 5% 포도당 100㏄에 연결하여 투여하는 투약 사고가 발생하였는데, 위 환자로부터 부작용이 나타나지 아니하자 위 환자의 단기의무기록지 기타란에 "1일째 아드리아마이신 60㎎ 대신 미톡싼트론 20㎎이 들어 갔음"이라고만 기재한 사실을 인정하였다.

If the facts are the same, the defendant recorded the treatment process in the short-term medical records of the patient's mass-scals, and recorded the fact that each of the above medication accident occurred by the nurse's rooms in each short-term medical records of both the patient's mass-scals and interest-free families, and recorded each of the above medical records in detail. The above patient's medical records did not record the fact that the above accident occurred after the above medication accident, i.e., the fact that there was no side effect, and it cannot be caused by the negligence. The judgment of the court below to the same purport is just and there is no error in the misapprehension of the legal principles as otherwise

3. Therefore, the appeal is dismissed. It is so decided as per Disposition by the assent of all participating judges.

Justices Jeong Jong-ho (Presiding Justice)