医患沟通记录常见问题及对策.pdfVIP

·?· ????????????2014????15????1?? 医患沟通记录常见问题及对策 ???衡水市哈励逊国际和平医院韩轶超彭 哗杨秀芳谢娜 摘要目的规范医患沟通记录，减少医患沟通缺陷及差错的发生，减少医疗纠纷，确保医疗质量。方法随机抽取我院 ??年???份终末病案，对病案中医患沟通记录进行质控，将质控结果录入???碇薪?型臣品治觥＝峁??份病案中 ??莶“复嬖谝交脊低?锹既毕荩?毕萋????ィ?毕莨??项次，较常见缺陷依次为：患者一般信息填写不全占?．?％；沟 通内容不全或简单占???ィ蝗鄙傧嘤Φ囊交脊低?锹迹?缥拮远?鲈禾富凹锹迹?奘溲把V破分G橥?馐榈日?．?％；非授权 ????????????????3??07???????????????????????????????????????????????????????????????????????????????????????? 关键词医患沟通记录；常见问题；原因分析；应对措施 C??on??? and Counte??e??????ofD0cto??p??entCommuni??tion??? ?? ???，?? ?，?謌 XiIlfang??Xie?， ??】【? Intem??onalPeace ????，???? 053000??HebeiIhince??China ??靌 0bj??ve? regIllate ???穚??? co??unication???，??? defects ?? eHors ? ?? ???穚??? ????? ??，??? ?? ???? ????，? order ? ??? ?? ???? ? ????綼????甅鲥?? ?筪?? ???? 585 ?珊?? medical ??? ? J??uary?? ? our hospital??Theresults ? qqality control ? ???穚??? communication ??? are ???? ? Excel??Reslllts A ?? ? 180 medical records ?? doctor??patient????緄? ??? defects??Defect?? ? ?．?％?? times)??The?? ?鷐? ?— f??ts? the order ??篜???縲?? ???甜???鱝?? ??????????；??????? content ? not ???? ? simple(6??15??)?? IJack ? ???穚??? co??unicati??record??鹳?棚???? discharge ?????? ??? ? ???????? ???鷗 tIIempies ????? consent(5??98??)??Communication??? ?印? ??锄????????????．?鯿?閚 S??ng??}lentlle????鷖 sense ? ???????，?眓??? ?? ???穚??? communicad??????ctively??reg??llate??????? ????撕? record??c??e??ctivelypre?? vent??e????? ? medical ????． ?? words ???—??? co??nic????reco??commonpro