摘要
目的分析病案中输血治疗知情同意书签署存在的问题,以提高书写质量,避免医疗纠纷。方法对某院2011年一、二季度输血病案分别于季度末进行质控,并将存在的缺陷项目进行统计。结果终末质控输血病案:一季度1330份,输血治疗知情同意书签署缺陷355份,占质控总数的26.69%,缺陷率最高的是输血治疗知情同意书缺医师签名189份,占质控总数的14.21%;二季度1584份,输血治疗知情同意书签署缺陷346份,占质控总数的21.84%,缺陷率最高的仍是输血治疗知情同意书缺医师签名163份,占质控总数的10.29%。结论医疗机构通过增加病案环节质量管理及加强医务人员对《执业医师法》、《医疗事故处理条例》等法律法规的学习,提高了医务人员的法律意识、证据意识,注重输血治疗知情同意书的填写质量,从而维护医患双方的合法权益,避免医疗纠纷。
Objective The analysis of medical records in transfusion therapy informed consent signed problems,improve the quality of blood transfusion therapy consent,avoid medical disputes.Methods The hospital in 2011one or two quarter on quarter blood transfusion records respectively at the end of the terminal quality control,and the defects of project statistics.Results The terminal quality control of blood transfusion records： a quarter of 1330 copies,transfusion therapy informed consent signed defect355accounted for26.69% of the total,quality control,defect rate was highest in transfusion for the treatment of informed consent without doctor＇s signature189,accounting for14.21% of the total quality control;the two quarter1584,transfusion therapy informed consent signed defects in 346copies total quality control,total 21.84%,defect rate are still the highest blood transfusion therapy of informed consent without doctor＇s signature163,accounting for10.29% of the total quality control.Conclusion Medical institution by increasing the medical record quality management and enhance the medical personnel in the＂ doctor law＂,＂ regulation of medical accident＂ and other laws and regulations study,raise the medical staff＇s awareness of the law,evidence of consciousness,pay attention to blood transfusion treatment consent quality,so as to safeguard the legitimate rights and interests of both doctors and patients,to avoid medical disputes.
出处
《中国病案》
2012年第5期15-16,共2页
Chinese Medical Record
