病案管理易发医疗纠纷的环节与预防措施探讨

目的:探讨和分析病案管理中易发生医疗纠纷的环节和预防措施。方法:加强对病案质量的控制和对病案环节的管理。结果:2012年医疗纠纷发生率2.55%(51/2000)明显低于2011年的7.50%(150/2000),法律知识掌握人数1458例明显多于2011年的560例,患者的满意度94.75%(1895/2000)明显高于2011年的60.0%(1200/2000),比较差异均有统计学意义(P0.05)。结论:在逐步实行病案双轨制管理和医疗纠纷逐渐增多的情况下,要增强医院的法律意识,同时加强对病案的管理,能够有效地减少和避免医疗纠纷的发生。

Discussion of Prone Links to Medical Disputes in the Medical Record Management and Preventive Measures

Objective：To investigate and analyze the medical record management in medical dispute link and preventive measures.Method：Strengthen the control of medical record quality and the management of the medical record link.Result：Incidence of medical disputes in 2012 was 2.55%（51/2000）,it was significantly lower than the 7.50%in 2011（150/2000）,the number of legal knowledge in 2012 was 1458 cases,it was more than 560 cases in 2011,the satisfaction rate of patients was 94.75%（1895/2000）,it was significantly higher than the 60.0%in 2011（1200/2000）,the differences had statistical significance（P〈0.05）.Conclusion：Medical record management and medical disputes are applicable shall be gradually practised in the gradually increasing number of cases,to enhance the legal awareness of hospital,strengthen the management of medical record at the same time,can effectively reduce and avoid the occurrence of medical disputes.