目的规范医患沟通记录,减少医患沟通缺陷及差错的发生,减少医疗纠纷,确保医疗质量。方法随机抽取我院2013年1月585份终末病案,对病案中医患沟通记录进行质控,将质控结果录入Excel表中进行统计分析。结果 585份病案中180份病案存在医患沟通记录缺陷,缺陷率30.77%,缺陷共199项次,较常见缺陷依次为:患者一般信息填写不全占10.94%;沟通内容不全或简单占6.15%;缺少相应的医患沟通记录,如无自动出院谈话记录,无输血及血制品知情同意书等占5.98%;非授权人签署沟通记录占3.07%。结论增强医师责任心,加强医患有效沟通,规范医患沟通记录,可以有效防止医疗纠纷的发生。 Objective To standardize the communication records between doctors and patients so as to reduce the communication gaps between doctors and patients and the occurrence of errors, reduce medical disputes and ensure the quality of medical care. Methods A total of 585 cases of terminal illness were randomly selected from our hospital in January 2013 to carry out quality control of medical records of patients in medical records. The quality control results were entered into the Excel table for statistical analysis. Results Of the 585 medical records, 180 medical records were found in the communication records between doctors and patients, with a defect rate of 30.77% and a total of 199 defects. The most common defects were as follows: 10.94% of patients’ incomplete information, 6.15% of incomplete communication or simple information, The corresponding doctor-patient communication records are lacking, such as no record of automatic hospital discharge conversation, no consent of blood transfusion and blood products, etc., accounting for 5.98%; and the non-authorized person’s communication record of signing is 3.07%. Conclusion To enhance the doctor’s sense of responsibility, strengthen the effective communication between doctors and patients, and standardize the communication records between doctors and patients, can effectively prevent the occurrence of medical disputes.