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目的探讨病案知情同意书书写存在的问题,提高病案质量,减少医疗纠纷发生。方法对我院2010年1月至2010年9月出院病案进行终末质控,并对缺陷项目进行统计。结果终末质控病案35,449份,缺陷病案2207份,其中知情同意书缺陷303份,占缺陷病案的13.73%。在缺陷知情同意书中,代理人签字缺委托书占35.65%,缺知情同意书占17.82%,知情同意书填写不全占30.69%,知情同意书填写不规范占15.84%。结论医疗机构应加强病案质量管理,医务人员要认真履行告知义务,落实患者知情同意权,规范填写知情同意书,从而有效地保护医患双方的合法权益,减少医疗纠纷的发生。
Objective To explore the existing problems in the written consent form of medical records, improve the quality of medical records and reduce the occurrence of medical disputes. Methods The end of January 2010 to September 2010 in our hospital discharge end-of-illness quality control, and statistics of defects. Results: There were 35,449 quality control and end-of-disease cases, 2207 cases of defective diseases, of which 303 cases were informed consent defects, accounting for 13.73% of the total. In the informed consent form of the defects, 35.65% of the agents lack signature in the signature, 17.82% lack the informed consent form, 30.69% did not complete the informed consent form and 15.84% did not form the informed consent form. Conclusion Medical institutions should strengthen the quality management of medical records. Medical personnel should conscientiously fulfill their obligation of disclosure, implement informed consent of patients, and complete the informed consent form, thus effectively protecting the legitimate rights and interests of both doctors and patients and reducing the incidence of medical disputes.