试论病案管理在防范医疗纠纷中的作用
朱文;孔庆迎;刘玉芝
【期刊名称】《中国继续医学教育》 【年(卷),期】2015(000)004
【摘要】Objective Actively explore the medical record management measures, in order to appear effective prevention of clinical medical disputes. Methods Review analysis of 50 cases of medical disputes of
medical records from our hospital in February 2009~May 2014, and summed up the reasons for problems. Results Because of the medical record management and medical dispute problem induced by a total of 8 cases, accounting for the total number of medical dispute cases 16%, among them, the ifrst page of medical records ifll in the basic information is not full, the lack of quality control and signature links not in time are the main problems. Conclusion Specification for the quality of clinical medical record writing, good control of each link, so that the medical record management more standardized and scientific, is an important means to reduce medical disputes.%目的：积极探讨病案管理措施，以有效防范临床医疗纠纷的出现。方法回顾性地分析我院在2009年2月～2014年5月50例医疗纠纷病案，并总结出问题出现原因。结果因病案管理问题而诱发的医疗纠纷共8例，占医疗纠纷案件总数的16%，其中，病案首页填写基本信息不全、缺乏环节质量控制与签名不及时等是其存在的主要问题。结论规范临床病案书写的质量，做好各环节的控制工作，使病案管理更
试论病案管理在防范医疗纠纷中的作用
