对一起医疗纠纷案例引发的病历保存问题的思考  

Thinking about Medical Records Save Problem Which Is Caused by Medical Dispute Case

作　　者：盖小荣[1] 彭华[1] 

机构地区：[1]中国医学科学院北京协和医院,北京市100730

出　　处：《中国病案》2012年第6期13-15,共3页Chinese Medical Record

摘　　要：本文以一纠纷案例为例,因医疗机构保管的门诊病历丢失而医学会根据《卫生部关于医疗机构不配合医疗事故技术鉴定所应承担的责任的批复》的规定,认为医方没有提交病历原件属于"不如实提供相关材料不配合做医疗事故鉴定",结果判定医疗机构应当承担医疗事故责任。病历丢失原因为三:一是患者或家属主观故意将部分内容拿走;二是某些医护人员为防范纠纷,主动将重要文件从病历中抽走,人员交替不慎丢失或者主观故意藏起;三是病历管理部门在整理病历时,将病历部门内容装订错误,无法查找。防范措施是应当加强管理,建立病历交接制度,遇有纠纷病历应提示病案科加强监控。The medical societies think hospital don＇ t submit original medical records is belong to ＇ Do not provide relevant materials do not cooperate with medical accident appraisal＇ according to ＇The health ministry about the responsibility of medical institutions do not cooperate with technical appraisal for medical accidents＇. The result is medical institutions shall be liable for medical accident liability. There are three reasons which lead to loss of medical records. Firstly, patients or their families take away part of records intentionally. Secondly, in order to prevent disputes, some health care workers take away important documents from the medical records, or the medical records were lost because of staff alternation or being hided subjectively. Thirdly, part of the medical records content can not find because of binding error during sorting. Preventive measures include strengthening management, improving medical handover system, and enhancing monitoring.

关 键 词：门诊病历 保存 纠纷 丢失 

分 类 号：R-051[医药卫生]