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目的规避病案时间记录存在缺陷,保证病案信息的法律依据的客观性、真实性。方法对某院2011年1月-6月份486份终末病案时间记录缺陷存在潜在的法律问题进行分析。结果 486份病案中342份病案时间记录存在误差,缺陷率70.4%,记录缺陷497项。时间记录缺陷严重影响了病案记载内容的客观性、真实性和严肃的法律性。结论强化医务人员法律意识教育,从法律角度认识准确记录时间的重要性,规范书写医疗文书,降低病历记录缺陷是质控工作的重点。
Aims To avoid the defects in the record of medical records and ensure the objectivity and authenticity of the legal basis of medical records. Methods The potential legal problems of 486 records of terminal illness record in a hospital from January to June in 2011 were analyzed. Results There were errors in the record of 342 medical records in 486 medical records, with a defect rate of 70.4% and 497 records of defects. The defects of time recording seriously affected the objectivity, authenticity and serious legal nature of the record. Conclusion It is the focus of quality control to strengthen legal education of medical personnel, recognize the importance of accurate record time from the perspective of law, standardize medical documents and reduce the record of medical record.