病案中签名缺陷分析与对策  

Defects Analysis on the Signature and Countermeasures in Medical Records

作　　者：万金兰 周庆林 曾侠林 张代斌 赵星星 王秋元 李静轩 Wan Jinlan Zhou Qlnghn Zeng Xialin Zhang Daibin Zhao Xingxing Wang Qiuyuan LI Jingxuan(TheTraditional Chinese Medicine Hospital, Jingmen 448000, Hubel Province, China Health and Family Planning Commission of Jingmen City, Jingmen 448000, HubeiProvince, China The Second People s Hospital in Jingmen City, Jingmen 448000, Hubei Province, China)

机构地区：[1]荆门市中医医院,荆门市448000 [2]荆门市卫生和计划生育委员会,荆门市448000 [3]荆门市第二人民医院,荆门市448000

出　　处：《中国病案》2016年第12期23-25,共3页Chinese Medical Record

摘　　要：目的查看调查归档病案中签名存在的缺陷,分析原因,提出处理措施。方法通过对某市9家医疗机构857份归档病案抽查,主要查看缺陷的类型及频次。结果缺陷病案642份,缺陷率达74.91%。病案首页无医务人员签名572次,手术相关文书中无手术者签名198次,病历中无医师签名152次、无护士签名66次,辅助检查报告单无医师签名144次、圆珠笔签名89次,无患者签名27次,患方无效签名135次。结论规范的签名与医务人员规范病历书写意识、重视签名程度、提高法律意识及加强科室质控相关。Objective To check the defects insignature existing in the medical records, and analyze the reasons and put forward countermeasures. Methods A total of 857medical records were randomly selected in nine medical institutions from April to December 2015 in Jingmen city, and the defects of the type and frequency were checked. Results There were 642 medical records withdefects, defect rate oi74. 91%. There were 572 times without medical staff signature in record homepage. The documents related to operation without operation physician signature were 152 times. The records without physician and nurse signature were 152 and 66 times. The auxiliary examination report withoutphysiciansignaturewere144 times andsignaturewith ball point pen were 89 times. There were no patient signature were 27 times and patients with invalid signature were 135 times. Conclusions Specification of the signature is associated with medical staff awareness, attention, legal consciousness and quality control.

关 键 词：归档病案 签名 缺陷 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]