基于电子病历引发医疗纠纷原因剖析

Reasons Analysis on the Medical Disputes Based on Electronic Medical Records

目的通过对电子病历系统缺陷分析,探索提高电子病历书写的有效措施,以减少和避免医疗纠纷的发生。方法对某三甲医院2014年1月-11月终末病历抽查,并结合医疗安全不良事件进行统计。结果3300份终末病案中问题病历占18.82%,主要集中在拷贝病历现象突出、责任心不强以及管理缺陷等方面。结论全方位加强电子病历管理是减少医疗纠纷、维护医疗安全的重要因素。

Objective Through defect analysis on the defects of electronic medical records system. to explore effective measures to improve electronic medical records writing in order to reduce and prevent the occurrence of medical disputes. Methods To conduct a spot check on the terminal medical records in a Grade A and Tertiary Hospital from January to November in 2014. and make statistics combined with the adverse events of medical safety.Results The defective medical records accounted for 18.82% in all 3300 terminal medical records. the problems mainly included serious copies of medical records. lack of responsibility and management defects. Conclusions To strengthen the comprehensive management of electronic medical records is an important factor in reducing medical disputes as well as maintaining medical security.