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目的提高病案质量管理水平,增强医务人员的法律意识及自我保护意识。方法对2002年-2008年我院因医疗纠纷被封存的40份病案进行分析。结果发生医疗纠纷较多的临床科室有骨外科、妇产科和颅脑外科;产生医疗纠纷的原因以医患沟通不足和期望值过高多见;封存病案的质量问题以字体潦草、涂改或错别字、漏填项目等多见。结论医疗行业是高风险的行业尤其是骨外科、妇产科和颅脑外科等临床科室。医务人员在执业过程中,不但要提高自己的业务能力,也要做好医患沟通、按规定书写病历,才能避免医疗纠纷的发生。
Objective To improve the quality of medical record management and to enhance the legal consciousness and self-protection awareness of medical personnel. Methods From 2002 to 2008, 40 cases of medical records in our hospital due to medical disputes were analyzed. Results The clinical departments with more medical disputes included bone surgery, obstetrics and gynecology and craniocerebral surgery. The causes of medical disputes were due to lack of communication between doctors and patients and the high expectations. The quality of sealed medical records was characterized by frivolous font, altered or misleading characters , Missed fill projects more common. Conclusion The medical industry is a high-risk industry especially in clinical departments such as orthopedics, obstetrics and gynecology and craniocerebral surgery. In the course of practicing, medical personnel should not only improve their operational capabilities but also communicate well with doctors and patients and write medical records as required to avoid medical disputes.