患者知情告知缺陷调研分析  

Investigation and Analysis on the Deficiency of Patients Informed Consent

作　　者：杨旭丽[1] 伍姗姗[1] 刘星 王志慧[1] 周政涛 陈志平 Yang Xuli;Wu Shanshan;Liu Xing;Wang Zhihui;Zhou Zhengtao;Chen Zhiping(The First Affiliated Hospital of Nanchang University,Nanchang 330006,Jiangxi Province,China;不详)

机构地区：[1]南昌大学第一附属医院,江西省南昌市330006

出　　处：《中国病案》2022年第2期10-13,共4页Chinese Medical Record

摘　　要：目的 探索目前院内患者知情告知制度执行中存在的问题,剖析其原因,探讨推行知情同意全电子化的可行性,持续改进医疗质量和效率。方法 采取整群抽样对知情同意缺陷较多的科室医师进行现场问卷调查,调研时间为2019年9月16日-2019年9月24日,共获取有效问卷367份。结果 知情告知缺陷排首位的是“知情告知不充分,缺书面知情同意书或缺患方签字”28.37%;缺医师签名的主要原因为“患者周转快,口头告知后病历归档时补书面签字”23.47%;医务人员不采用电子签名的主要原因为“病历系统卡顿,等待时间过长影响工作效率”18.64%。结论 患者知情告知中存在的必要信息欠缺、沟通告知不充分和签名不及时等一系列问题,均会严重影响医院医疗质量与安全,亟待采取打造信息化闭环管理、全面推行电子签名及病历无纸化等措施解决。Objective Explore the problems existing in the implementation of informed consent system in hospitals,analyze the reasons,and explore the feasibility of implementing all-electronic informed consent,so as to continuously improve the medical quality and efficiency.Method The cluster sampling was used to conduct an on-site questionnaire survey of physicians in departments with more defects in informed consent.A total of 367 valid questionnaires were obtained from September 16,2019 to September 24,2019.Results The first defect of informed consent is "insufficient informed information of patients(or their families),lack of written informed consent or signature of patients" 28.37%.The main reasons for the lack of doctor’s signature in informed consent is "fast turnover of patients,doctor’s written signature when filing medical records after oral notification" 23.47%.The main reason why medical staff did not use all-electric signatures is "The medical record system is too slow and the waiting time is too long which affects work efficiency" 18.64%.Conclusions A series of problems in the informed notification,such as lack of necessary information,insufficient communication and notification,and untimely signatures,will seriously affect the quality and safety of hospital medical care.It is urgent to take measures to solve the problem,such as building informatized closed-loop management,promoting electronic signature and paperless medical records.

关 键 词：知情告知 问卷调查 电子签名 医疗质量 

分 类 号：R197.323[医药卫生—卫生事业管理]