Abstract: As the adduce evidence in identification of medical tangle, medical records not only have a vital role to the expert conclusion, but also do as the directly evidence in solving medical tangle. There have the relative specific laws and regulations to medical record writing, copying, archived and unsealed, preservation in our country. It has the extremely vital significance on prevention of medical tangle and occurrence of medical disputes after the processing, if the medical institutions can perform legal regulations about medical record and fulfill the obligation and power about medical record. In order to provide the references to prevention of medical tangle and occurrence of medical disputes after the processing, this paper proposed the view of common problems related to medical records in identification of medical tangle.

摘要： 病历作为医疗损害司法鉴定的举证依据，对于鉴定结论有着至关重要的作用，也是解决医疗纠纷的直接依据。我国相关法律法规对于病历书写、复印、封存和启封、保存等有相对具体的规定。如果医疗机构能够就履行法律条例的规定，在病历资料相关问题上善尽义务和权力，对防范医疗纠纷的发生和医疗纠纷后的处理有极其重要的意义。本文就医疗损害司法鉴定中常见的病历资料的相关问题提出自己的看法，以期能为医疗纠纷的预防和医疗损害司法鉴定提供参考意见。

关键词: 医疗纠纷 司法鉴定 医疗损害 病历缺陷 病历管理, medical tangle, judicial authentication, medical malpractice, medical records defects, medical record managment