完善知情同意书填写 防范医疗风险  

Maintaining the Rights and Interests of both the Patients and Care-givers by Improving the Documentation of the Consent Sheets

作　　者：王宇红[1] 冯家琳[1] 林少晖[1] 高琨[1] 陈文权[1] 魏丽云[1] 林敏[1] 

机构地区：[1]汕头大学医学院第二附属医院信息科,汕头市515041

出　　处：《中国病案》2006年第9期24-26,共3页Chinese Medical Record

基　　金：广东省卫生厅医学科研基金立项课题课题编号A2005451

摘　　要：目的探讨患者知情同意书的完善与医疗风险的防范。方法抽查我院四年23份医疗投诉案例,结合相关出院病案,参照国务院新颁《医疗事故处理条例》,分析探讨医疗纠纷的成因。结果我院近年来医患纠纷的发生率无明显增高：知情同意书缺页或缺项有所减少：对患者病情、治疗、危险性和预后等据实通报是对患者权力的维护：而知情同意书的完善,本质上有益于医院管理的规范、医患纠纷的防范,其实质也是对医务人员利益的保护。结论完善知情同意的病案内容,严格知情同意书的书写质量,加大知情同意书缺页缺项的处理力度,是维护医患双方权益,减少医患纠纷发生的新举措。Objective To explore the right of knowing and consenting and maintain the right of both the care-givers and the patients. Method According to the new regulations for handling medical malpractice by the State Council, we analyzed the medical records and disputes. Results It is important to pay Attention to the consenting sheets and truth notification about patient＇s conditions, treatment, fatalness, and prognosis. It does not only vindicate the patient＇s right, but also protect the interests of medical personnel. Conclusion For vindicating the right and interests of doctors and patient＇s, reducing medical disputes, It is a new act to perfect the content of consenting sheets and improve the quality of consenting sheets.

关 键 词：知情同意书 病案 权益 医疗风险 

分 类 号：R-051[医药卫生]