医疗争议住院病案的管理

The Management of Hospitalized Medical Records with Treatment Disputes

目的分析近三年医疗争议病案情况,探讨医疗争议患者住院病案的管理。方法调取2012年到2014年北京地区以心肺血管为特色的某三甲综合医院279份医疗争议病案资料进行分析。结果 279份医疗争议病案资料中涉及重点科室心脏外科168份,占60.22%;心脏内科56份,占20.07%。三年期间的使用频次分别为3次,次均复印页数为246页。结论医疗争议主要涉及重点科室的危重症患者,是特殊病案保管的重要部分,需要专人进行特殊流程的管理,以确保安全及满足医院管理、法律诉讼等环节的正常使用。

Objective To investigate the management of hospitalized medical records with treatment disputes through analyzing the situations on the disputed medical records in recent three years. Methods 279 cases of medical records were selected from a Three A and Tertiary Hospital in Beijing which featured by cardiopulmonary vessel from 2012 to 2014. Results There were 168 cases of disputed medical records related department of cardiac surgery, which accounted for 60. 22%, 56 cases of department of cardiac, which accounted for 20. 07%. The frequency of usage was 3 respectively in the three years, and the average duplication page was 246. Conclusions Medical disputes mainly related the critically ill patients in emphasized departments, and also the important part of particular medical records need special progress management so as to ensure the security utilization of hospital management and lawsuit as well as other situations.