182份封存病历管理相关问题研究  

Management Related Problems in 182 Sealed Medical Records

作　　者：张雪梅[1] 张灵丽[1] 杨帆[1] 彭城[1] 

机构地区：[1]广州军区武汉总医院,湖北武汉430070

出　　处：《中国卫生质量管理》2016年第4期34-36,共3页Chinese Health Quality Management

摘　　要：回顾性研究2000年-2015年医院所有封存病历182份。其中,经司法和医学会鉴定判决或协商解决纠纷病历占32.42%,存在医疗过错纠纷封存病历占64.41%,医院全责占18.42%,以外科、手术病历居多。指出了封存病历的发生年份、涉及科室、纠纷性质、诉讼情况以及存在的主要缺陷,探讨封存病历与法律法规、医疗过错、治疗科室、病案管理以及病历质量的关系,认为法律法规的出台对封存病历有显著影响,封存病历复印件有利于后续病案管理工作的开展。In 2000 to 2015, all 182 sealed medical records in a hospital were retrospectively investigated, in which judicial and medical identification judgment or negotiated settlement of disputes records accounted for 32.42%, sealed records with medi- cal mistakes disputes accounted for 64.41%, and records with full responsibility of hospital accounted for 18.42%, and the ma- jority of medical records were in surgery departments or with operations. Sealed medical record is a conventional means for hospital medical disputes, the introduction of laws and regulations has a significant impact on the sealed records, and archive copies of medical records can help to carry out the follow -up case management work.

关 键 词：封存病历 医疗纠纷 病案管理 

分 类 号：R197.323[医药卫生—卫生事业管理]