摘要
目的分析我院手术知情同意书的填写现状,探讨其规范化管理的措施。方法对我院2005年1月1日至6月30日出院,需建立手术知情同意书的外科病案3024份进行统计分析。结果全部符合要求的2570份,占85%,存在问题的454份,占15%。454份病案中,无患者及家属签字的有34份,家属签字未注明与患者关系的有201份,有35份在“是否同意手术”一栏没有填写意见,有8份病危通知书及31份输血同意书只有家属或患者签名,其他项目无任何内容,有6份术前谈话记录单无实施手术的名称,28份无上级医生签名。结论规范手术知情同意书的填写,能有效地保护医患双方的合法权益,有利于提高病历的内涵质量,丰富病案的内容。
To analyze the current situation of the documentation of operation consent in our hospital, and investigate the measure of standardized management of the medical records （TMR）. Method 3024 medical records from surgery in 6 months （2005.1-2005.6）, which need operation consents, were analyzed. Results 454 records with problems were found. Among them, in 201 cases, the relationship between the signers and the patients are not identified; in 35 eases, there was no opinion about ＂agreement with operation whether or not＂; in 8 notices of critical conditions and 35 consents of blood transfusion, there is not any other content but the signatures of patients or their family members; in 6 eases, there are no conversation records between doctors and their patients and no signatures of the higher authorities in cases. Conclusion The standardized management of operation consent can protect the legitimate interests of both the doctors and patients, and increase the connotation of the medical records.
出处
《中国病案》
2006年第3期24-25,共2页
Chinese Medical Record
关键词
手术知情同意书
质量控制
病案管理
operation informed consent
quality control
medical records
