目的探讨运行病历中医疗告知行为缺陷的现状。方法对我院2006年9月100份运行病历中,医疗告知执行情况进行随机抽样检查。结果运行病历中医疗告知所存在的问题较为多见。各科知情同意书全部符合要求的为57.69%~88.89%,存在问题的为23.33%~44.31%,未进行告知的为11.11%~13.33%。结论填写好知情同意书,必须转变观念,提高对知情同意书重要性的认识,要进一步强化知情同意权的管理,尤其在环节质量方面提高管理,减少潜在风险。 Objective To investigate the status of medical notification behavior defects in running medical records. [Methods] Random sampling was performed on the implementation of medical notification in the 100 medical records of September 2006 in our hospital. Results There are many problems in medical notification in running medical records. 57.69%~88.89% of all subjects were in compliance with the requirements, 23.33%~44.31% of the subjects had problems, and 11.11%~13.33% did not make any informed consent. Conclusion In order to complete the informed consent form, it is necessary to change the concept, raise the awareness of the importance of the informed consent form, and further strengthen the management of the right to informed consent, especially in terms of link quality, to improve management and reduce potential risks.