病案中医患沟通方面存在的问题与对策

Defects Analysis on the Communication System and Countermeasures in Medical Records

目的查看某市归档病案中医患沟通方面存在的问题,分析原因,提出处理措施。方法抽查9家医疗机构857份病案,查看在医患沟通方面存在问题的类型及频次。结果问题病案709份,缺陷率达82.73%。缺知情告知书219份,知情告知书内容不全674份,患方未签名或签名不规范的27份,医患双方签字时间填写不规范的802份,非患者本人签名又未填与患者关系的病案211份。结论只有提高医务人员的业务素质和法律意识、规范地进行医患沟通,才能保障医疗质量安全。

Objective To check the problems in doctor-patient communication system existing in the medical record of our city, analyze the reasons and put forward countermeasures. Methods 857 medical records were randomly selected in nine medical institutions, and the problems of the type and frequency were checked. Results There were 709 medical records with problems, defect rate of 82.73%. Lack of the medical records of 219, content is not complete of 674, signature problem of 27, time problem of 802, signature of incompletely relationship of 211.Conclusions The implementation of doctor-patient communication system is closely related to medical personnel quality and legal consciousness. To ensure medical quality and safety, we should improve medical staff＇s quality and legal consciousness, and standardize the doctor-patient communication at the same time.