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目的分析医疗谈话记录存在的问题,探讨管理策略。方法对5个科室2013年8月-2013年11月的203份谈话记录存在的问题进行分类统计。结果谈话记录存在问题共39份,问题发生率19.2%(39/203),其中存在一项问题29份,发生率14.3%(29/203),存在两项及两项以上问题10份,发生率4.9%(10/203)。所有谈话记录中共存在问题54项,平均每份1.4项(54/39),69.2%(27/39)有沟通无完整的记录。结论医务工作者充分履行告知义务,认真做好医疗谈话并形成文字记录,提高病历记录质量,减少医疗纠纷。
Objective To analyze the existing problems of medical conversation records and to explore management strategies. Methods We classified the problems in 203 records of conversations from August 2013 to November 2013 in 5 departments. Results There were 39 questions and 19.2% (39/203) of the problems in the record of the conversation. Among them, there were 29 questions of one kind, the incidence rate was 14.3% (29/203), there were 10 items of 2 items and 2 items or more, The rate was 4.9% (10/203). There were 54 questions in all conversations, with an average of 1.4 items (54/39) and 69.2% (27/39) respectively. There was no complete record of communication. Conclusion Medical workers fully fulfill their obligation of disclosure, conscientiously do medical talks and form written records, improve the quality of medical records and reduce medical disputes.