回顾分析40份封存病案看病案质量的控制

Analysis of the Quality Control of Medical Records by Reviewing 40 Archive records

目的提高病案质量管理水平,增强医务人员的法律意识及自我保护意识。方法对2002年-2008年我院因医疗纠纷被封存的40份病案进行分析。结果发生医疗纠纷较多的临床科室有骨外科、妇产科和颅脑外科;产生医疗纠纷的原因以医患沟通不足和期望值过高多见;封存病案的质量问题以字体潦草、涂改或错别字、漏填项目等多见。结论医疗行业是高风险的行业尤其是骨外科、妇产科和颅脑外科等临床科室。医务人员在执业过程中,不但要提高自己的业务能力,也要做好医患沟通、按规定书写病历,才能避免医疗纠纷的发生。

Objective To improve quality control of medical records and enhance health professionals＇ consciousness of law and self- protecting. Methods 40 archive records owing to medical disputes from 2002 to 2008 were analyzed in our hospital.Results Most medical disputes occurred at de- partments of bone surgery,obstetrics and gynecology, and brain - surgery than other departments. The primary causes of medical disputes were lack of communication and skyscraping expectations. Illegible font,altered or wrong writing, and leaked items- filling were main problems in the quality of archive records. Conclusion The medical industry is a industry at high risk, especially departments of bone surgery, obstetrics and gynecology, and brain - surgery. Therefore, medical staffs, not only need to enhance their operational capacity, but also make good physician - patient relationship and write medical records according to the provisions, in order to avoid the occurrence of medical disputes.