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

[2] Methods of preparing medical records

[1] In a case where a doctor provides a patient with a medical treatment, he/she shall prepare a medical treatment record and signed with the detailed matters and opinions regarding the relevant medical treatment under Article 21(1) of the Medical Service Act, and any person who has not prepared a medical treatment 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 allow him/her to accurately record the patient's condition and progress of the medical treatment without omitting any information about the patient's progress and to allow him/her to use it for continuing patient treatment thereafter, so that he/she can provide other relevant medical personnel with such information so that the patient can be provided with appropriate medical treatment, and after the completion of the medical treatment, he/she can use it as data

[2] A doctor shall choose the time and method to easily and accurately understand matters and opinions concerning the medical practice and to make prompt and accurate entries in preparing the medical examination and treatment records. However, since the Medical Service Act does not have specific provisions concerning the time and method of preparing the medical examination and treatment records, if a doctor states that matters and opinions concerning the medical practice can be used in accordance with the above purpose, regardless of its name, it constitutes a medical examination and treatment record under the above Act, and the specific time and method of preparing the medical examination and treatment records should be within the reasonable discretion of the doctor concerned within the scope of ensuring accuracy of the records in light of the contents and the treatment process of the patient in question. Article 17 subparagraph 1 of the Enforcement Rule of the Medical Service Act provides that "(a) the address, name, resident registration number, and family history of the person who received the medical examination and treatment, and (b) the main symptoms, diagnosis results, results and prediction, (c) details of treatment (such as injection, medication, treatment, etc.)."

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

Defendant

Prosecutor

Attorney Gangwon-gu

Seoul District Court Decision 96No8673 delivered on April 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 does not prepare 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 allow the doctor himself/herself to accurately record the patient's condition and progress of medical treatment without omitting any information about the patient's progress and to allow him/her to use it for continuing patient treatment thereafter, and to provide other relevant medical professionals with such information so that the patient can be provided with appropriate medical treatment and use it as data to determine the propriety of the relevant medical treatment after the completion of the medical treatment.

Therefore, a doctor shall choose the time and method to easily and accurately record matters and opinions concerning his medical practice by making his best best in preparing the medical treatment records. However, since there are no specific provisions regarding the time and method of preparing the medical treatment records in the same Act, if a doctor states that matters and opinions concerning medical treatment can be used in accordance with the above purpose, it constitutes a medical treatment record under the above Act, regardless of its name, and the specific time and method of preparing the medical treatment should be within the reasonable discretion of the doctor concerned within the scope of ensuring accuracy of the records in light of the contents of the medical act in question and the treatment progress of the patient concerned. Article 17 subparagraph 1 (a) of the Enforcement Rule of the same Act provides that the address, name, resident registration number, and history of the person who received the medical treatment shall be within the scope of ensuring accuracy of the records. (b) The main symptoms, diagnosis results, diagnosis results, details of treatment (such as injection, medication, treatment, etc.).

2. 원심판결 이유에 의하면, 원심은, 피고인은 원심 판시의 수혈사고가 있었던 1995. 7. 20. 무렵 서울대학교병원 내과 114병동에 있는 39명 가량의 입원환자를 의사 두진웅과 함께 주치의로서 진료를 담당하고 있었는데, 두진웅이 1995. 7. 19.부터 같은 달 21.까지 휴가중이어서 위 수혈사고가 발생한 당일 21:00경에는 피고인이 담당하는 환자의 수가 평소보다 2배 가량 많았던 사실, 피고인은 위 수혈사고가 발생하자 그 직후 위 환자 최홍남에 대한 응급검사를 시행하고 신부전방지를 위해 다량의 수액을 투여하고 이뇨제를 사용하는 등 처치를 하면서 위 환자의 경과를 관찰하다가 다음날 01:00경 병원 당직실에서 취침한 사실, 피고인은 같은 날 오전에 기상하여 위 39명의 환자들에 대한 회진 등 진료를 담당하다가 그 업무를 마친 이후인 1995. 7. 21. 밤 늦게부터 두진웅이 휴가를 마치고 출근한 1995. 7. 22. 08:00경 사이에 위 수혈사고가 있었던 환자 최홍남에 대한 의무기록지를 작성하였는데, 그 의무기록지에 "간경화, 식도정맥류 하열로 인한 출혈(간성혼수)로 입원, 혼수에 대한 치료 후 의식수준이 명료해졌으나, 7. 19. 다시 출혈이 있어 S-B튜브 삽입 지혈 후, 7. 20. 경화요법시행, 혈색소치 6.8로 수혈하는 과정에서 부적합한 농축적혈구 80㏄ 가량 수혈됨, 현재 신부전방지를 위해 수액 투여 및 요 알칼리화, 이뇨제 사용중, 주의관찰 요망, 수액투여, 소변량, 전해질 균형, 폐부종발생 여부, 잘 봐 주세요"라고 기재하였으며, 1995. 7. 22. 10:00경 이후에는 두진웅이 주치의로서 위 환자를 치료한 사실을 인정한 다음, 피고인은 위 최홍남에 대한 의료행위에 관한 사항과 소견을 상세히 기록하고 서명한 진료기록부를 작성하였다고 볼 수 있다고 판단하여, 피고인에 대하여 무죄를 선고한 제1심판결을 유지하였다.

In light of the records, the decision of the court below to the same purport is just, and there is no error of law by misunderstanding facts against the rules of evidence, and in light of the contents of the defendant's medical act against the maximum Hongnam and the treatment progress of the above maximum Hongnam, etc., the above medical records prepared by the defendant can ensure accuracy of the records, and it shall be deemed that the above medical records of the defendant's medical act against the above maximum Hongnam as well as the opinion about the medical act against the above maximum Hongnam are recorded in detail in accordance with Article 21 (1) of the same Act. Thus, the judgment below to the same purport is just, and there is no error of law by misunderstanding the legal principles as otherwise alleged in the grounds for appeal. The grounds for appeal cannot be accepted.

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

Justices Park Jong-chul (Presiding Justice)