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目的:对病案中手术知情同意书存在的问题进行调查并探讨对策。方法:抽取2007-01-01/2007-12-31有手术知情同意书的3980份出院病案进行检查。结果:3621份合格(91%),359份存在问题(9%)。常见问题为:内容缺乏规范、签名不符合标准、内容有涂改等。结论:手术知情同意书是手术科室病案中的重要部分,进行规范化管理有利于提高病案质量,有助于保护医患双方的合法权益。
OBJECTIVE: To investigate and discuss the problems existing in the informed consent forms of medical records. Methods: 3980 discharged medical records with informed consent form from January 2007 to January 2007 were examined. Results: 3621 passes (91%) and 359 issues (9%). Common problems are: lack of content specification, the signature does not meet the standards, such as content modification. Conclusion: The informed consent of surgery is an important part of the surgical department’s medical records. To standardize the management helps to improve the quality of medical records and helps to protect the legitimate rights and interests of both doctors and patients.