Objective To discuss the deficiencies of inform ation consent form , improve the quality of medical records and reduce medical tangle. Methods Termina1 quality control of discharge medical records was taken from January to September 2010 in our hospital. Results 35,449 medical records were termina1 quality controlled, and 2207 medical records have deficiencies. 303 information consent forms have deficiencies, accounting for 13 .73％ . Lack of power of attorney is 35.65％ , lack of informed consent is 1 7.82％ , informed consent fill in incomplete is 30.69％ , and lack of standardization is 15.84％ . Conclusion Some measures such as medical record quality management should be strengthened, medical personnel should conscientiously fulfill the obligations, standardized fill in informed consent should be taken to effectively protect the legitimate interests of both doctors and patients and reduce the incidence of medical tangle.%目的 探讨病案知情同意书书写存在的问题,提高病案质量,减少医疗纠纷发生.方法 对我院2010年1月至2010年9月出院病案进行终末质控,并对缺陷项目进行统计.结果 终末质控病案35,449份,缺陷病案2207份,其中知情同意书缺陷303份,占缺陷病案的13.73%.在缺陷知情同意书中,代理人签字缺委托书占35.65%,缺知情同意书占17.82%,知情同意书填写不全占30.69%,知情同意书填写不规范占15.84%.结论 医疗机构应加强病案质量管理,医务人员要认真履行告知义务,落实患者知情同意权,规范填写知情同意书,从而有效地保护医患双方的合法权益,减少医疗纠纷的发生.
展开▼
