某公立医院法院判决书病案相关问题分析  

Analysis on Related Problems of A Public Hospital Court Judgment

作　　者：蔡志玲 周炯 陈政 谭旭彤 张国杰 郑文婷 张杰石[1] 朱玲 陈伊航 彭华 Cai Zhiling;Zhou Jiong;Chen Zheng;Tan Xutong;Zhang Guojie;Zheng Wenting;Zhang Jieshi;Zhu Ling;Chen Yihang;Peng Hua(Department of Medical Affairs,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China;不详)

机构地区：[1]中国医学科学院北京协和医院医务处,北京市100730

出　　处：《中国病案》2024年第6期1-3,共3页Chinese Medical Record

基　　金：中央高校基本科研业务费专项资金资助(3332022087)。

摘　　要：目的分析医疗纠纷法院判决书中病案问题的具体类别和发生率以及法院判决定责时,病案相关问题与判决医疗机构有无责任的相关性,以期达到归类病案高诉讼风险点并提出病案质控提升管理措施的目的。方法本研究纳入某公立医院2017年1月1日-2022年12月31日6年间收到的125例法院判决书,针对判决书中患方、鉴定机构和法院3个主体所提出有病案缺陷的病案进行分层分析,包括诉讼主体质疑病案情况、病案问题类型。结果6年间收到的125例法院判决书,其中缺陷病案73例,问题主要集中在病案真实性、完整性、准确性和内涵质量。门诊病案问题集中在病案缺失占31.03%、风险告知不足占27.59%、随诊不到位占17.24%和病案错误占7.24%等。住院病案问题集中在风险告知不足占44.07%、病案内涵质量问题占27.12%、封存病案问题占6.78%、检查报告错误占6.78%和病案真实性、及时性问题占6.78%。本研究中未发现病案有无问题与法院判定医疗机构是否有责任存在统计学差异。结论从法律层面来看,为维护医方权益,病案作为诉讼重要依据,医疗机构仍应重视病历书写规范,建议从诉讼风险点角度强化病历书写培训、从提高病历内涵质量角度构建全方位的质控体系和从病案完整性角度健全病案保存机制。Objectives To analyze the specific categories and incidence of medical record problems in medical dispute court judgments and the correlation between medical record related problems and the judgment of whether medical institutions are liable when the court decides responsibility,so as to classify the high litigation risk points of medical records and propose measures to improve the quality control of medical records.Methods 125 cases of court judgments received by a public hospital during the 6-year period from January 1st,2017 to December 31st,2022 were included in this study.The medical records with medical record defects proposed by patients,appraisal institutions and courts in the judgments were analyzed by stratification,including the subject of the lawsuit to question the medical case,and the types of hospitalization and medical record problems.Results Among the 125 cases of court judgments received by a public hospital from 2017 to 2022,there were 73 cases of defective medical records.The problems mainly focused on the authenticity,completeness,accuracy and quality of medical records.The problems of outpatient medical records mainly include missing medical records(31.03%),insufficient risk notification(27.59%),inadequate follow-up(17.24%)and errors(7.24%).The problems of inpatient medical records were concentrated in insufficient risk notification(44.07%),connotation and quality of medical records(27.12%),sealing of medical records(6.78%),error of inspection report(6.78%)and authenticity and timeliness of medical records(6.78%).In this study,no statistical difference was found between whether there was a problem in the medical record and whether the court decided that the medical institution was responsible.Conclusions From the legal point of view,in order to protect the rights and interests of the medical side,medical records as an important basis for litigation,medical institutions should still pay attention to the standardization of writing medical records.It was suggested to strengthen the training of

关 键 词：法院判决 病案 问题 管理 

分 类 号：D922.16[政治法律—宪法学与行政法学] D926.2[政治法律—法学] R-051[医药卫生]