从病案信息对外利用谈医疗纠纷的防范

目的探讨病案信息对外利用过程,以人为本科学管理,共建和谐的医患关系。方法对2004年~2006年社会各界复印病案的需求、目的进行统计、分析。结果要求复印的患者不断增多,因不熟识相关流程及制度,容易引发新的矛盾。用途主要是医疗费报销,其次是复诊、转诊、建立家庭健康档案等。个别患者质疑医疗质量要求复印所有资料,要求封存病案的现象也增多。结论患者的维权意识非常强烈,医务人员应增强法制观念,尊重患者的知情权(包括知晓相关制度),在确保医疗质量的同时重视病案书写质量,优化工作流程,有助于防范医疗纠纷。

On the Precaution of the Medical Disputes from the Management of the Medical Record

Objective To explore the process of applying information in the medical records, to construct scientific management based human-oriented, and build up the harmonious relationship of between physicians and patients. Methods To calculate and analyze the data from the medical records copied from 2004 to 2006 which are categorized according to social needs and motivations. Results The number of patients who require copying the medical records is sharply increasing. Being unfamiliar with co-related process and instructions, misunderstandings happened. The main purposes of copying medical records are submitting medical expenses, and the others including re-checking and exchanging to other hospitals, furthermore, constructing family health records etc. And being doubtful about medical quality, someone requires duplicating all the information. Conclusion The patients have strong sense of right-protecting awareness. The medical staff should enhance law cautiousness and respect the patients' rights to know the truth including the related regulations. At the same time, they should ensure the medical qualities, and focus on the quality of the documentation of the medical records, upgrade working process, as will be helpful to avoid medical disputes.