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(영문) 대구지방법원 서부지원 2020.02.06 2019고정26
의료법위반
Text

The defendant shall be innocent.

Reasons

1. The summary of the facts charged is the intention of Defendant A affiliated with B.

A medical person shall keep an electronic medical record book, etc. and record in detail the matters and opinions concerning medical practices, such as the main symptoms, diagnosis and treatment of the patient.

Nevertheless, on January 9, 2014, the Defendant treated the patient C at the above emergency department B in the above emergency department, and stated the progress of the examination and treatment in the medical records and did not affix any digital signature.

2. The facts charged in the instant case are based on the premise that the Defendant directly treated C and drafted a medical record.

According to the medical records(325 pages of investigation records) with C, it is confirmed that the defendant was electronically input as if he/she provided medical treatment with C in January 9, 2014.

However, according to the nursing record paper for C (Investigation Record 328 pages), C is written as being treated by doctor D on January 9, 2014, which is not the defendant, and also stated as being treated by doctor D on January 9, 2020 as being attached to B's response to the order to submit documents on January 9, 2020, even in the nursing record book for C, which is attached to B's response to the order to submit documents.

[Along with the deletion of the patient's personal information on each nursing response note attached to the above reply, the possibility of entering C into a computerized system as if the defendant was diagnosed with C on January 9, 2014, and the evidence submitted by the prosecutor alone was that the defendant prepared a medical record of C on the above date. Thus, even after the medical record was prepared on January 9, 2014, it cannot be ruled out that the possibility of entering C in a computerized system could not be ruled out, as if the defendant provided C on the above date, due to an error in computer or occupational duty. The evidence submitted by the prosecutor alone was that the defendant prepared a medical record of C on the above date.

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