器官移植伦理规范化审查对病历书写的要求  

Requirements of the Standardized Ethics Review of Organ Transplantation on the Writing of Medical Records

作　　者：崔洋海[1] 李小莹[1] 冀冰心[1] 王欣[1] 张艳红[1] CuiYanghai;li Xiaoying;Ji Binxin;Wang Xin;Zhang Yanhong(Xuanwu Hospital,Capital Medical University,Beijing 100053,China)

机构地区：[1]首都医科大学宣武医院

出　　处：《中国病案》2019年第12期27-30,共4页Chinese Medical Record

摘　　要：本文阐述了器官移植伦理委员会审查现状、审查原则、目的、意义及审查的重点内容,提出建立符合我国国情的器官移植伦理委员会规范化审查标准势在必行,以确保患者在移植过程、医疗质量与安全的权益。器官移植病历书写反映器官移植技术临床应用的整个治疗过程,因此器官移植伦理委员会规范化审查对病案书写提出了更高的要求。进一步从病案质量,病程记录,知情同意书,医师资质等方面伦理审查要求进行了阐述,列举了病程记录及知情同意书中常见的问题,并提出加强病历书写人员对器官移植法律、法规、制度等知识培训和加强病案质量控制等改进措施,从而为器官移植伦理委员会规范化审查病历书写提供参考。This paper expounds the review aspects of the organ transplantation ethics committee, such as the review status, principle, purpose and key contents. It puts forward that it is imperative to establish a standardized review standard of organ transplantation ethics committee in line with China’s national conditions, so as to ensure the medical quality and safety of patients in the process of transplantation. The medical record writing of Organ transplant reflects the whole treatment process of clinical organ transplantation technology, so the standardized review of the organ transplantation ethics committee has higher requirements for the medical record writing.The paper further expounds ethical review requirements from the medical record quality, course records, informed consent, the physician qualification and so on. It lists the common problems in the course of records and informed consent, and puts forward to strengthen the knowledge training of the medical record writing person such as organ transplantation of laws, regulations, system, etc. And which strengthensimprovement measures of medical record quality control, so as to improve the quality of medical record writing. It can provide the reference for the medical record writing of the organ transplant ethics committee standardized review.

关 键 词：器官移植 伦理委员会 器官捐献 器官分配 伦理审查 病案 

分 类 号：R197.323[医药卫生—卫生事业管理]