内科系统医疗谈话记录存在的问题和管理策略

The Problems and Management Strategies of Internal medicine Medical Conversation Record

目的分析医疗谈话记录存在的问题,探讨管理策略。方法对5个科室2013年8月-2013年11月的203份谈话记录存在的问题进行分类统计。结果谈话记录存在问题共39份,问题发生率19.2%(39/203),其中存在一项问题29份,发生率14.3%(29/203),存在两项及两项以上问题10份,发生率4.9%(10/203)。所有谈话记录中共存在问题54项,平均每份1.4项(54/39),69.2%(27/39)有沟通无完整的记录。结论医务工作者充分履行告知义务,认真做好医疗谈话并形成文字记录,提高病历记录质量,减少医疗纠纷。

Objective To analyze the problems of the medical conversation record to explore its management strategy. Methods Analyzing existing problems of 203 conversation records in five kinds of internal medicine from August 2013 to November 2013. Results There were 39 copies of conversation record have problems accounted for 19.2% （39/203）, in which one problem 29 accounted for 14.3% （29/203）. Two and two above problems accounted for 4.9% （10/203）. There were 54 problems in conversation records, each copy was 1.4 on average （ 54/39 ）. 69.2% （ 27/39 ） conversation records were incomplete. Conclusion Medical worker should fully fulfill its obligation to inform, do a good job in medical conversation records, improve the quality of medical records, reduce medical disputes.