1080份知情同意书填写缺陷分析

目的探讨病案中知情同意书填写存在的问题,并采取有效的改进措施,提高病案质量。方法分析我院2011年1～11月出院病案,对1 080份知情同意书填写情况进行统计分析。结果 1 080份知情同意书中,缺陷最多的是一般项目填写不全350例,占32.4%;其次是多次操作或治疗只签一次知情同意书150例,占13.9%。结论正确填写好每份知情同意书,提高医务人员对知情同意书的重要认识,是减少医疗纠纷的重要途径。

ANALYSIS OF THE DEFECTS IN 1080 INFORMED CONSENT FORMS

Objective To discuss the deficiencies of informed consent form,and take effective measures to improve the quality of medical record. Methods Analyze the medical records from January 2011 to November 2011 in our hospital and make the statistical analysis. Results In the 1080 Informed Consent Forms,the general items filled out insufficiently is the largest defect which has 350 cases,accounting for 32.4%,followed by is that repeated operation or treatment only signed once in the informed consent which have 150 cases,accounting for 13.9%. Conclusion Medical personnel should fill in each informed consent form correctly and understand that it is an important way to reduce medical disputes.