知情同意书的缺陷和对策

The Defects and Countermeasures of Informed Consent Agreement

目的提高知情同意书的书写质量。方法随机抽查本院2010年7月到2011年6月出院病案880份,进行认真检查,发现存在的问题和缺陷,分析造成缺陷的原因,寻找相应的有效对策。结果知情同意书存在的问题有:完全民事行为能力人由家属签名时,签名家属未被授权;无民事行为能力人不是法定监护人签名;项目填写不全;无医师签名或有修改、涂改等。分析原因主要是医务人员法律意识、病案质量意识不强,工作态度不认真,上级医师把关不严,奖惩不得力。针对问题采取相应对策,包括提高医务人员法律意识、增强对病案质量的认识,加强质量的监督及奖惩。结论规范知情同意书的书写,以减少医疗纠纷的隐患。

Objectives to improve the writing quality of informed consent agreement.Methods 880 copies of hospitalization medical records are randomly selected from July to June 2011 in our hospital,had carefully examined,for finding out the existing problems and defects and analyzing the reasons of it,searching for related effect countermeasures.Results The existing problems of it are as followings： family of person with full capacity of civil conduct sign for them without authorizing;non-legal guardian sign for person with no full capacity of civil conduct;incomplete item filling;without signature of physician or with mending or altered and etc.The main reasons are that faint consciousness of legal and medical records quality of medical staffs,non-careful work attitude,non-strict guarantee of superior physicians and little reward and punishment.Aiming at these problems,we adopt related countermeasures including improvement of legal consciousness of medical staff,strengthening of the knowledge about medical records quality and supervision and reward and punishment of quality.Conclusions The writing of informed consent agreement should be standardized for reducing hinder trouble of medical tangle.