[1]张雪梅,张灵丽,杨帆,等.182份封存病历管理相关问题研究[J].中国卫生质量管理,2016,23(04):34-36.[doi:10.13912/j.cnki.chqm.2016.23.3.12]

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182份封存病历管理相关问题研究

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 第23卷期数: 2016年04期页码: 34-36 栏目: 医疗质量出版日期: 2016-05-28

作者:: 张雪梅；张灵丽；杨帆；彭城; 广州军区武汉总医院

关键词:: 封存病历; 医疗纠纷; 病案管理

Keywords:: Sealed Records; Medical Disputes; Management of Medical Records

DOI:: 10.13912/j.cnki.chqm.2016.23.3.12

摘要:: 回顾性研究2000年-2015年医院所有封存病历182份。其中，经司法和医学会鉴定判决或协商解决纠纷病历占32.42%，存在医疗过错纠纷封存病历占64.41%，医院全责占18.42%，以外科、手术病历居多。指出了封存病历的发生年份、涉及科室、纠纷性质、诉讼情况以及存在的主要缺陷，探讨封存病历与法律法规、医疗过错、治疗科室、病案管理以及病历质量的关系，认为法律法规的出台对封存病历有显著影响，封存病历复印件有利于后续病案管理工作的开展。

Abstract:: In 2000 to 2015, all 182 sealed medical records in a hospital were retrospectively investigated, in which judicial and medical identification judgment or negotiated settlement of disputes records accounted for 32.42%, sealed records with medical mistakes disputes accounted for 64.41%, and records with full responsibility of hospital accounted for 18.42%, and the majority of medical records were in surgery departments or with operations. Sealed medical record is a conventional means for hospital medical disputes, the introduction of laws and regulations has a significant impact on the sealed records, and archive copies of medical records can help to carry out the follow-up case management work.

参考文献/References:

［1］毕玉田，武军，程晓斌.医疗机构应用《侵权责任法》的思考［J］.中国卫生质量管理，2011，18（2）：71-74.

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更新日期/Last Update: 2016-05-28