尸检告知缺陷案例分析及管理对策  

Analysis on Autopsy Inform Defects Cases and Management Countermeasure

作　　者：顾跃静[1] 王全虹[1] 杜淑英[1] 白家琪[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》2016年第1期28-29,41,共3页Chinese Medical Record

摘　　要：医务人员有履行尸检告知的义务,尸检告知有利于患者家属冷静思考,一旦发生医疗纠纷有利于纠纷的处理,是判定医疗后果的客观依据。本文结合案例分析,针对医务人员履行尸检告知义务中存在的问题,如履行告知义务的意识差、告知对象不符合法律规定、告知的尸检内容不全面、病历记录不完善等,提出应加强对医务人员法律意识的培训,管理部门通过制作统一的尸体解剖告知模板加以规范以及将尸检解剖告知书纳入病案质量管理,对于明确死因,避免医疗纠纷,防范由于尸检告知缺陷给医患双方带来的不利后果具有现实意义。Medical staff have the obligation to inform the relatives of the patients about autopsy which is benefit for them to thinking calmly, and also it is an objective evidence to judge medical treatment results and helpful for the dealing if medical dispute occurs. Combined with the actual cases, this article put forward that we should strengthen the training of legal awareness of the medical staff aimed at the problems existing in the inform obligation of the medical staff, such as lack of the awareness of performing inform obligation, the objectives were inconformity with the regulations of the law, incomplete of inform content and imperfect of medical recording. The management departments could formulate united autopsy inform template so as to standardize the situation and also bring it into the management of medical records quality, which had actual significance for elaborate death reasons, avoid medical disputes and prevent the bad results of autopsy inform defects to both the patients and doctors.

关 键 词：尸检 告知缺陷 病历记录 

分 类 号：D919.4[医药卫生—法医学]