病历书写与医疗纠纷的相关性研究

An Investigation about the Relationship between the Documentation of Medical Records and Medical Dissensions

目的 探讨新形势下病历书写与医疗纠纷的关系。方法 对照新《医疗事故处理条例》,分析目前住院病历中常见的书写缺陷及对策。结果 住院志、病程记录、各种辅助报告单存在亟待重视、解决的书写缺陷;各种知情同意书尚需建立健全。结论 主观重视、客观负责、严格质控每一份病历的书写,完善知情同意书的设计和签署,防范医疗纠纷的发生。

Objective To study the relationship between documentation and dissension in new medical situation. Methods According to the new punishment regulation of medical malpractice, Analysis the writing deficit in medical documentation and possible countermeasure. Rusults There are writing deficit in hospitalization record, progress note,various kinds of assist information paper and various consent book. We must pay attention to them and solve better. Conclusion Perfect medical documentation is import to prevent medical dissension.