46例医疗纠纷病案质量分析

Quality Analysis of 46 Cases of Medical Dispute Medical Records

目的探讨纠纷病案中存在的问题,提高病案书写质量,减少医疗纠纷发生。方法对某院2010年6月-2014年6月住院发生医疗纠纷案例46例的病案进行分析、总结。结果 46例医疗纠纷病案存在缺陷33例,其中医务人员未有效履行知情告知义务12例,占36.36%;三级医师查房制度落实不到位6例,占18.18%;病案书写不规范4例,占12.12%;病案记录不及时3例,占9.09%。结论规范病案书写和加强病案质量管理是减少医疗纠纷发生的有效途径。

Objective To investigate the problems in disputes medical records, to improve the quality of medical care, to reduce the occurrence of medical disputes. Methods Analyzing and summing the 46 disputes medical records from June 2010 to June 2014. Results In the 46 medical records, 33 was flawed. Including 12 cases of the medical personnel has not effectively fulfill the informed consent obligation, accounted for 36.36%;6 cases of three level round system implementation is not in place, Accounted for 18.18%;4 cases of irregular writing, accounted for 12.12%; 3 cases of not timely medical records, accounted for 9.09%. Conslusion Standarding the writing of medical record and strengthening the management of medical records are the effective ways to reduce the occurrence of medical disputes.