围手术期病历书写中的医学伦理学特点  

The characteristics ethics of documetation in para-operation records

作　　者：刘春玲[1] 邓应梅[1] 王文美[2] 

机构地区：[1]首都医科大学宣武医院病案统计科,北京市100053 [2]首都医科大学附属安贞医院透析科,北京市100029

出　　处：《中国病案》2009年第12期15-15,共1页Chinese Medical Record

摘　　要：医务人员在医疗实践中,要用医学伦理规范自己的行为,将伦理原则贯穿于医疗临床活动的整个过程,并且体现在病历书写中。在围手术期的记录中,术前讨论、手术记录及术后病程的书写,应重点反映出有利与不伤害的原则,而知情同意书在实践"自主与尊重"原则的基础上,强调的是获得同意的过程,而不仅仅是用书面、签字等形式获得同意的文件。Medical ethnics will go throughout a case of clinical activities as well as medical documentation.So,it should be carried out to restrict one＇s behavior for medical practice.Peri-operation notes of Pre-operation discussion,operation note and post-operation note should abide by benefit and no hurt and consents should be on self-determination and respect.It is not only the signature but also the process of acquired agreement.

关 键 词：医学伦理学 病历 病历书写 手术 

分 类 号：R197.3[医药卫生—卫生事业管理]