医患沟通记录常见问题及对策

目的规范医患沟通记录，减少医患沟通缺陷及差错的发生，减少医疗纠纷，确保医疗质量。方法随机抽取我院2013年1月585份终末病案，对病案中医患沟通记录进行质控，将质控结果录入Excel表中进行统计分析。结果585份病案中180份病案存在医患沟通记录缺陷，缺陷率30．77％，缺陷共199项次，较常见缺陷依次为：患者一般信息填写不全占10．94％；沟通内容不全或简单占6．15％；缺少相应的医患沟通记录，如无自动出院谈话记录，无输血及血制品知情同意书等占5．98％；非授权人签署沟通记录占3．07％。结论增强医师责任心，加强医患有效沟通，规范医患沟通记录，可以有效防止医疗纠纷的发生。

Common Problem and Countermeasures of Doctor-patient Communication Record

Objective To regulate doctor-patient communication record, reduce defects and errors in the doctor-patient communication, reduce the medical disputes, in order to ensure the quality of medical treatment. Methods Randomly selected 585 terminal medical record in January 2013 in our hospital. The results of quality control of doctor-patient communication record are analyzed in Excel. Results A total of 180 medical records have doctor-patient communication record defects. Defect rate is 30.77% （ 199 times ）. The more common defects in the order are： Patients with general information incomplete （ 10.94% ）; Communication content is not complete or simple （6.15%）; Lack of doctor-patient communication record such as no automatic discharge conversation record or Blood transfusion and adjuvant therapies of informed consent（5.98% ）; Communication record signed by Unauthorized person（ 3.07% ）. Conclusion Strengthen the physicians sense of responsibility, strengthen the doctor-patient communication effectively, regulate doctor-patient communication record, can effectively pre- vent the occurrence of medical disputes.