从医疗赔偿看病案管理的重要性  

The Importance of Medical Records Management from the Aspect of Medical Compensation

作　　者：许德华[1] 华立[1] 李宗泽[1] 

机构地区：[1]海军总医院海空勤体检中心

出　　处：《中国病案》2011年第7期5-6,共2页Chinese Medical Record

摘　　要：回顾分析我院医疗赔偿中封存的165份病案,针对赔偿病案存在的问题,分析原因,提出对策。其中造成较多医疗赔偿的有15份,主要问题为病案书写不及时、医护病案脱节、电子病案粘贴不当、上级医师把关不严、法律意识淡薄等。医院为此赔偿几百万元。文章提示重视病案的书写与安全管理,可有效地减少医疗纠纷与医疗赔偿。165 blocked medical records in medical compensation are retrospectively analyzed in our hospital.Aiming at the existing problems of compensation medical records,we analyze the reasons and put forward countermeasures.There are 15 of them causing more medical compensation,which the main problems are that,untimely writing of medical records,disconnection between medical nursing and medical records,improper paste of electronic medical records,non-rigorousness control of senior doctors and weak law consciousness.Our hospital pays several million for these compensations.This article indicates that we should value the writing and safety management of medical records for effectively reducing medical tangle and compensation.

关 键 词：医疗纠纷 病案 赔偿 管理 

分 类 号：R197.3[医药卫生—卫生事业管理]