医疗知情同意书和告知书的内涵质量管理  

Connotation Quality Management of Medical Informed Consent and Inform Note

作　　者：宋树权 姚德厚 贾小兵 曾祥玲 辛艳 彭龙平 李燕娜 周雪勤 

机构地区：[1]蓝海医院心血管内科

出　　处：《中国病案》2014年第4期18-20,共3页Chinese Medical Record

摘　　要：目的调查患者对医疗知情同意书和告知书的认识和对其内容的理解程度，从而了解医务工作者对患者的告知现状和所产生的效果。方法2013年7月～12月间，用问卷的形式对既往接受过住院治疗，且签署过知情同意书或（和）告知书的97名无沟通障碍的患者进行匿名调查。结果患者认为知情同意书是尊重患者的选择权和知情同意权的占62．9％（61／97），认为知情同意书是医师为了推卸责任的占29．9％（29／97），认为医疗方案由医师确定，知情同意书只是形式的占7．2％（7／97）。十分熟悉、基本熟悉、不熟悉和完全不知道自己签署的知情同意书或（和）告知书内容分别为26．8％（26／97），30．9％（30／97），（33．0％）32／97，9．3％（9／97）。结论提高医务工作者的法律意识，加强医患沟通，充分履行医师的告知义务，让患者充分了解拟行医疗方案、替代方案、特殊检查和治疗可能受益情况和潜在的并发症，不接受医疗建议的风险，是减少纠纷的有效途径之一。Objective To understand the degree of understanding and the understanding of the content of the informed consent, to understand the inform status quo and its effect. Methods A anonymous questionnaire survey was .taken to investigate 97 patients without communication barriers who had accepted treatment in other hospitals and had signed informed consents or （and） inform notes From July 2013 to December 2013. Results Patients＇ thought of informed consent is Respect for the patient＇s choice and informed consent account for 62.9% （61/97）; Patients＇ thought of informed consent is a doctor to shirk the responsibility account for 29.9% （29/97）; Patients＇ thought of the program is determined by doctors, informed consent is just a form account for 7.2% （7/97）. Very familiar with, basic familiar with, unfamiliar with, and have no idea of it respectively were 26.8%（26/97）,30.9%（30/97）,（33.0%）32/97,9.3%（9/97）. Conclusion We should improve the legal awareness of health workers, strengthen the doctor-patient communication, fully fulfill the obligation of doctors, so that patients fully understand the Health care scheme, alternative solution, special inspection and treatment, may benefit situation and potential complications, the risk of without take medical advices are effective ways to reduce disputes.

关 键 词：医疗 知情同意书 告知书 内涵 

分 类 号：R-05[医药卫生]