1432例病案的质量分析和法理思考.pdfVIP

中国医院统计 2002年9月第9卷第3期 1 432例病案的质量分析和法理思考 林春金 陈南升 林 勤 【摘要】 目的 试从卫生法制建设的角度探讨病案书写缺陷的原因与对策。方法 对病案缺陷进行分类统 计，对照(医疗机构管理条例、(执业医师法、(医疗护理技术操作常规规定，分析原因。结果 本组查出缺陷 3670项次，平均每份2．56项次。此外，有40份没有实习医师书写的入院记录；有 4份对病情分析不全、治疗计划 不周、其中1例治疗有严重失误。结论 强化“书证”意识和技术操作常规观念，实施患者“知情同意权”，是病案质 量管理中的一项经常性的管理教育工作。 【关键词】 病案书写 书证 法定义务 公开病案 中图分类号：R197．323 文献标识码：A 文章编号：1006—5253(2002)03—0146—03 Quality Analysis of 1432 Medical Records and Consideration of Legal Principle Lin Chu in，Chen Nansheng，Lin Qin．Fujian Provincial Corps Hospital，Chinese People S Armed Polwe Forces．Fuzhou 350019 【Abstract】 Objective To study the cause and strategy of defects in medical record writing from the angle of health legal construction．Methods A classified statistics was made of defects in medical record．By the standards of Manage— ment Regulation of Medical Institutions，Medical Practician Law，and Medical and Nursing Technical Operation Routine， to analyse the causes．Results 3670 item—times of defects were found in this group，average 2．56 item—times per record． In addition，there were 40 records withoUt adimission record written by interns．There were 4 records withoUt complete condition analysis and well—considered therapeutic plan。in one of which serious therapeutic mistakes occurred．Conclusion Consciousness of written certificateand sense of technical operation routine must be strengthened，and the right of knowing the facts of a medical record and consent must be carried OUt．That should become a routine task of management education in medical record quality management． 【Key words】 Medical record writing Written certificate Legal duties Open medical record 为了进一步探讨我院病案书写质量的现状、病 题，将缺陷“扣分法”改为“缺陷项目累计法”。 案在处理医疗纠纷中的法学“书证”作用，我们查阅 1．3 将全部的“病案质量检查登记表”，