大型综合医院电子知情同意标准库建设的实践探索  

A practical exploration on the construction of electronic informed consent standard library in large general hospitals

作　　者：冯楚[1] 李盈[1] 初菁菁 FENG Chu;LI Ying;CHU Jingjing(The First Affiliated Hospital of College of Medicine of Zhejiang University,Hangzhou 310003,China)

机构地区：[1]浙江大学医学院附属第一医院,浙江杭州310003

出　　处：《现代医院》2024年第9期1377-1380,共4页Modern Hospitals

摘　　要：目的推进知情同意标准库建设,实现知情同意书规范化管理。方法对知情同意书进行标准化分类、设置版本号,规范其结构、内容,围绕签署场景、术种等进行整合使用,并实现患者电子签署。结果四大院区158个病区患者电子签名全覆盖,病历质检中知情同意书的缺陷比例由2022年的25.93%下降至2023年的3.7%,投诉信访中知情告知不足的案例占比由2022年的8.9%下降至2023年的4.5%。结论知情同意书标准库建设,加快了病案无纸化进程,提高了临床工作效率和病案质量,促进了医患关系,提升了医疗质量。Objective To promote the construction of a standardized informed consent library and achieve standardized management of informed consent forms.Methods The informed consent forms were standardized and classified,assigned version numbers,and structured and content were regulated.The forms were integrated and used according to signing scenarios and surgical types,and electronic signatures from patients were implemented.Results The initiative achieved full coverage of electronic patient signatures across a total of 158 wards in four campuses.The defect rate of informed consent forms found in medical record quality inspections dropped from 25.93%in 2022 to 3.7%in 2023.The proportion of cases with inadequate informed consent in complaints and petitions decreased from 8.9%in 2022 to 4.5%in 2023.Conclusion The construction of a standardized informed consent library has accelerated the process of paperless medical records,improved clinical work efficiency and medical record quality,enhanced doctor-patient relationships,and elevated the overall quality of medical care.

关 键 词：知情同意书 电子签名 标准库 

分 类 号：R197.323.1[医药卫生—卫生事业管理]