Abstract: Medical records are important objective materials for forensic injury examination. Defects in medical records will interfere with forensic injury examination directly or indirectly. The impact of common defects in medical records on forensic injury examination is analyzed. It is proposed that medical workers who are engaged in trauma treatment should enhance their legal awareness and improve the quality of medical records.

Key words: injury, medical record, defect, forensic examination

摘要： 病历是创伤病人进行司法鉴定的重要客观资料,病历书写中相关缺陷直接或间接影响着司法鉴定活动的正常进行。分析创伤科病历书写中的一些常见缺陷对司法鉴定带来影响,强调提高创伤科医务人员的法律意识及病历书写质量是保证司法鉴定结论客观公正的重要因素之一。

关键词: 创伤, 病历, 缺陷, 司法鉴定