整形美容住院病历书写与医疗纠纷的防范

Medical Record Writing and Prevention of Medical Disputes in Plastic and Cosmetic Surgery

目的探讨整形美容科住院病历书写与医疗纠纷的防范,避免和减少纠纷的发生。方法对某院近5年来入院行整形美容手术导致医疗纠纷案例41例进行回顾性分析、总结,并采取相应的管理措施。结果严格规范的病历书写和加强病案质量管理能有效减少整形美容医疗纠纷的发生。结论在整形美容医疗活动中,应建立健全完善的病历书写管理制度,医务人员及时准确完整规范地记录好每一份病案,能够有效防范医疗纠纷的发生。

Objective To discuss the prevention of medical disputes and medical records of plastic and cosmetic surgery,to avoid and reduce the occurrence of disputes. Methods 41 medical disputes cases of the past 5 years to be admitted to the hospital in plastic surgery patients were retrospectively analyzed and summarized,and to take the corresponding management measures. Results This could effectively reduce the occurrence of plastic and cosmetic medical disputes by strict standardization of medical records writing and strengthening the quality management of medical records. Conclusion In the plastic cosmetic medical activities,a effective system of medical records management should be established. The medical staff recorded every medical record in a timely,accurate and complete manner,can effectively prevent the occurrence of medical disputes.