摘要
目的了解我站知情同意书填写情况,探讨规范化管理措施。方法抽取我站2008年5月1日-12月30日出院已归档,需要建立知情同意书的计划生育病案共900份进行分析。结果全部符合要求648份,占72%;存在问题的252份,占28%;未建立知情同意书的48份,无患者家属签字的8份,无医师签字的16份。结论正确写好知情同意书,能有效地保护医患的合法权益,减少医疗纠纷。
Objective To grasp the fill quality of informed consents and to investigate the standardized management measures.Methods By analyze 900 family planning medical records which were needed to establish informed consents from May 1,2008 to Dec 30,2008 in our station.Results 648 medical records meet the requirements,which is 72%.There are some problems in 252 records which is 28%.48 medical records＇ informed consents were not established.8 of them weren＇t signed by patients＇ family members,and 16 of them weren＇t signed by doctors.Conclusion Doctors and patients＇ legal rights can be effectively protected by good writing of informed consents and medical malpractice can alse be reduced.
出处
《中国病案》
2011年第2期14-15,共2页
Chinese Medical Record
关键词
知情同意书
填写质量
分析
Informed consent
Fill quality
Analize
