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目的探讨纠纷病案中存在的问题,提高病案书写质量,减少医疗纠纷发生。方法对某院2010年6月-2014年6月住院发生医疗纠纷案例46例的病案进行分析、总结。结果 46例医疗纠纷病案存在缺陷33例,其中医务人员未有效履行知情告知义务12例,占36.36%;三级医师查房制度落实不到位6例,占18.18%;病案书写不规范4例,占12.12%;病案记录不及时3例,占9.09%。结论规范病案书写和加强病案质量管理是减少医疗纠纷发生的有效途径。
Objective To explore the existing problems in the case of disputes, improve the quality of medical records and reduce the occurrence of medical disputes. Methods A hospital from June 2010 to June 2014 cases of medical malpractice occurred in hospital cases of 46 cases were analyzed and summarized. Results A total of 46 cases of medical disputes were found to be defective in 33 cases, among which, medical staff did not effectively perform the obligation of informing and informing 12 cases (36.36%), 6 cases (18.18% Accounting for 12.12%; medical record is not timely in 3 cases, accounting for 9.09%. Conclusion It is an effective way to reduce the number of medical disputes by standardizing the writing of medical records and strengthening the quality management of medical records.