| 医疗告知文书患方签署情况调查 |
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| 引用本文： | 刘克新,杨翔宇,郑琳,高晓圆,尹思璐.医疗告知文书患方签署情况调查[J].中国病案,2011,12(8):24-25. |
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| 作者姓名： | 刘克新 杨翔宇 郑琳 高晓圆 尹思璐 |
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| 作者单位： | 解放军总医院病案管理科,北京市,100853 |
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| 摘 要： | 目的调查医疗告知文书患方签署情况,查找问题所在,提高医疗告知文书的质量。方法回顾性调查2011年1月出院病案9635份中的医疗告知文书患方签署情况,包括知情同意书和委托书。结果对病情、手术、操作有告知的病案7521份,患者本人签署1178份,患者亲属签署1124份,正确签署2302份,合格率30.61%。医师如果能正确指导患方正确填写告知文书,杜绝漏项,正确率可以提高到87.71%。由表格设计繁琐造成了43.66%的不合格率。结论合理设计医疗告知文书表格,增加可操作性;对医师进行法律知识的培训,增加法律意识;定期检查,及时发现问题,及时改正是提高医疗告知文书患方签署质量的有效方法。
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| 关 键 词： | 医疗告知文书 患方签署 质量 |
Signature Condition Survey of Medical Inform Documents of Patients |
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| Liu Kexin,Yang Xiangyu,Zheng lin,Gao Xiaoyuan,Yin Silu.Signature Condition Survey of Medical Inform Documents of Patients[J].Chinese Medical Record,2011,12(8):24-25. |
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| Authors: | Liu Kexin Yang Xiangyu Zheng lin Gao Xiaoyuan Yin Silu |
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| Institution: | Liu Kexin,Yang Xiangyu,Zheng lin,Gao Xiaoyuan,Yin Silu,Medical Records Management Department of Chinese PLA General Hospital,Beijing 100853,China |
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| Abstract: | Objective To investigate signature of patients about medical inform documents.To find the problem and improve the quality of inform documents.Methods Investigating signature of patients about 9635 medical inform documents of discharge medical records retrospectively in January 2011,including inform documents and power of attorney.Results There were 7521 medical records which have inform documents about patient's condition,surgeries and operation.The patients signed 1178 inform documents,patients relatives s... |
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| Keywords: | Medical inform documents Signature of patients Quality |
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