新形势下住院病历管理存在问题的调查分析  

Investigation and analysis in existing problems in management of medical records under new situation

作　　者：张英辉[1] 柳相珍[1] 

机构地区：[1]山东大学第二医院,济南250033

出　　处：《中国实用护理杂志（下旬版）》2008年第9期40-41,共2页Chinese Journal of Practical Nursing

摘　　要：目的研究新形势下住院病历管理的问题，尤其是发生患方要求封存病历或抢夺病历时，医护人员的认知情况，探讨医护人员对新形势下住院病历管理存在的问题及应对措施。方法采用自行设计问卷对医生75人、护士75人进行问卷调查，并对结果进行分析。结果对各种问题完全不知者医生占27．7％、护士占29．4％；医护人员完全不知比例最高的问题为：患方提出封存病历后，医护人员应如何应对？医生占50．0％，护士占55．7％。结论医护人员应熟悉相关法律知识，加强对住院病历的管理意识，使病历在纠纷处理或法庭举证中真正起到应有的证据作用。Objective To explore the problems existing in management of medical records under new situation, especially the cognition of medical workers when the patients required to seal up or seize medical records. As a result, we further discussed existing problems in management of medical records under new situation and the countermeasures. Methods Self-designed questionnaires were used to investigate 75 doctors and 75 nurses. The results underwent analysis. Results The analysis showed that 27.7% doctors and 29.4% nurses didn＇t know any question.While 50.0% doctors and 55.7% nurses didn＇t know how to deal with when patients wanted to seal up the medical records,which became the issue that most doctors and nurses did not know. Conclusions Doctors and nurses should be familiar with concerned legal knowledges and strengthen the consciousness of medical records management in order to make the medical records the real evidence in the dispute settlement or court of law.

关 键 词：住院病历 医护人员 管理 对策 

分 类 号：R197.323[医药卫生—卫生事业管理] R563.1[医药卫生—公共卫生与预防医学]