产科病历书写思考

Writing and Thinking of Obstetric Medical Records

近几年,医疗纠纷的增多,加之产科面对的特殊患者群,使产科医务人员工作压力加大,进一步导致产科成为高风险,高纠纷率的临床科室。病历是临床事实最客观、准确的文字表达,具有法律效应。但往往部分医师在病历书写上会出现内容缺失或不完整,从而出现一些低级错误甚至引起纠纷。笔者从事妇产科临床工作10余年,就一些病例中出现的常见问题提出思考,以此与妇产科同仁们共勉。

In recent years, the increase of medical disputes and the special patient population which obstetric doctors faced on are increasing the work pressure of obstetrical medical staff, and those further lead to high risk, high dispute rate in department of obstetrics. Medical record is the most objective clinical facts and accurate text expression. It has legal effect. But often part of physicians in medical record writing will appear on the content of missing or incomplete, and some low- level errors even make disputes. Author is engaged in obstetrics and gynecology clinical work for nearly ten years, and put forward to think in some problems of cases, in order to share experience with obstetrics and gynecology colleagues.