医疗知情同意书使用现状分析及对策  

Situation Analysis and Solution of Using Medical Information Consent

作　　者：刘琼[1] 林佩彤[1] 雷雪萍[1] 刘颜[1] LIU Qiong,LIN Pei-tong,LEI Xue-ping,LIU Yan （Shenzhen Hospital,Beijing University,Shenzhen 510515,China）

机构地区：[1]北京大学深圳医院病案统计科,广东深圳510515

出　　处：《医学信息》2010年第4期864-865,共2页Journal of Medical Information

基　　金：广东省自然科学基金博士启动项目（项目编号：9451803601002999）

摘　　要：目的调查了解病案知情同意书在使用过程中存在的问题，以期提高病案质量，消除医疗隐患。方法随机抽查2008年12月出院病案3260份．自制调查表进行统计分析。结果发现知情同意书的书写存在多种缺陷。结论医院应通过加强法律知识培训，加强病案检查力度和加快信息化管理过程等措施来加强知情同意书的管理。Objective To investigate and understand the status of patients archives informed consent in using process in order to improve the quality of medical records management and eliminate the medical risks. Methods 3260 patients archives in Dec.2008 were sampled randomly,and made the statistical analysis by self-made questionnaire. Result Many points in the informed consent were found not correct. Conclusions The suitable training in law knowledge,the strict medical record checks for the related person and the advanced management by means of information technology etc. measures strengthen the informed consent in the proper condition.

关 键 词：知情同意书 现状分析 管理对策 

分 类 号：R197.322[医药卫生—卫生事业管理;医药卫生—公共卫生与预防医学]