病案缺陷导致医疗纠纷赔付案例分析  

Compensation Case Analysis of Medical Record Defects Lead to Medical Disputes

作　　者：顾跃静[1] 王全虹[1] 杜淑英[1] 李晓杨[1] 

机构地区：[1]首都医科大学宣武医院,北京市100053

出　　处：《中国病案》2014年第8期22-23,共2页Chinese Medical Record

摘　　要：病案资料的及时性、完整性归档是病案管理的重点和难点。病案资料的不完整,给医院及病案管理人员的工作带来不必要的麻烦,以致影响患者的后续诊治、费用报销、保险理赔等,引起医患纠纷,甚至诉诸法律的事件时有发生。本文通过与病案资料相关的3个案例分析,查找对策,旨在提高医务人员对病案资料完整性的重视,保障患者的权利,避免医患纠纷的发生。The timeliness, completeness archive of medical records are the key and difficult points of medical record management. Incomplete medical record data can bring unnecessary trouble to the hospital and the medical record management working. It can affect patients＇ follow-up treatment, expenses, insurance claims, etc., cause medical disputes, or even to resort to law. We find the countermeasure through the three case studies related to medical records data in order to improve the attention of the medical staff to the medical record data integrity, protect the fights of patients, avoid the occurrence of medical disputes.

关 键 词：病案资料 缺陷 医疗纠纷 

分 类 号：R197.323[医药卫生—卫生事业管理]