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目的了解手术和有创操作医疗告知现状,寻找差距,探讨改进措施。方法选择2012年1月-3月某院出院病案,对其中1890份手术知情同意书和1200份有创操作知情同意书填写情况,进行回顾性对照分析。结果手术和有创操作告知患者率分别为67.4%和17.8%,主治医师告知率分别为31.6%和7.6%,手术前一天告知率为79.2%,有创操作当日告知率为92.7%,手术医疗告知好于有创操作告知。结论走出医师医疗告知认识误区,尊重患者知情同意权,规范履行医师责任告知义务。
Objective To understand the status quo of surgical and invasive operation medical information, to find out the gaps and to explore the improvement measures. Methods A hospital discharge from January to March in 2012 was selected, and 1890 informed consent form and 1,200 informed consent forms for invasive operation were retrospectively analyzed. Results The rates of operation and invasive operation were 67.4% and 17.8% respectively. The rate of attending physicians was 31.6% and 7.6% respectively. The rate of notification was 79.2% on the day prior to operation and 92.7% on the day of invasive operation. Tell better than invasive operation to inform. Conclusion Out of the doctor’s medical knowledge misunderstanding, respect for patients informed consent, standardize the obligation to inform the obligation to perform physicians.