叶细珍

[摘要] 目的 分析病案管理中常见医患纠纷原因及预防方式。 方法 根据病案优化管理实施前后，选取2011年1月～2012年12月期间实施常规病案管理的我院200例病例资料，将其作为传统管理组，并选取从2013年1月～2014年12月期间实施科学透明化病案管理的我院200例病例资料，将其作为优化管理组，对比两组的医患纠纷发生率、患者对临床工作的满意度评价和病案管理质量，并对常见医患纠纷原因进行总结分析。 结果 两组医患纠纷发生率相比较，优化管理组明显低于传统管理组（P<0.05）。对病案管理中医患纠纷的原因进行调查发现主要包括医患双方在医学认知和疾病认知上存在差异、患者对医疗质量期望值太高、病案管理缺陷（如病案立法滞后、病案不完整、医护人员病案法律责任意识低等）。两组对临床工作的满意度评价和病案管理质量相比较：优化管理组明显高于传统管理组（P<0.05）。 结论 医患纠纷发生的原因较多，通过科学透明化病案管理的实施，有效降低了医患纠纷发生率，提高了临床工作满意度和病案管理质量，值得推广。

[关键词] 病案管理；常见医患纠纷原因；预防方式

[中图分类号] R-051 [文献标识码] B [文章编号] 2095-0616（2016）01-184-04

[Abstract] Objective To analyze and study the common cause of doctor-patient dispute and prevention methods in medical record management. Methods According to the pre-and post implementation of medical record optimal management， 200 clinical data， who were adopted conventional medical record management in our hospital from January 2011 to December 2012 were selected as traditional management group， while the other 200 clinical data， who were adopted scientific lucidification medical record management in our hospital from January 2013 to December 2014 were selected as optimal management group. To compared the incidence rate of doctor-patient dispute， the patients' satisfaction evaluation of clinical work， the quality of medical record management， to summarize and analyze the common cause of doctor-patient dispute. Results The incidence rate of doctor-patient dispute in optimal management group was obviously lower than which in traditional management group（P<0.05）. The investigation on doctor-patient dispute in medical record management showed that， there were differences on medical cognition and illness perceptions between doctors and patients， patients had too high expectation medical quality， there were defects on medical record management， such as hysteretic legislation of medical record， incomplete medical record， low awareness of legal duty of medical record on medical staff. The patients' satisfaction evaluation of clinical work， the quality of medical record management in optimal management group were obviously higher than which in traditional management group（P<0.05）. Conclusion Scientific lucidification medical record management adopted on the much causes of doctor-patient dispute， could effectively reduce the incidence rate of doctor-patient dispute， to improve the patients' satisfaction evaluation of clinical work and the quality of medical record management， is worthy of clinical popularization.

[Key words] Medical record management； Common cause of doctor-patient dispute； Prevention methods

所谓病案，即为所有医疗文件总称，为医疗行为一种文字化载体，也是科技档案管理重要组成部分，其对医务人员所有医疗行为资料、文字和图像等进行记录，因此，病案管理是医院管理的中药内容，其受档案法法规和医疗卫生技术相关法规的约束和调整[1]。目前，我国医疗机构病案管理较为散乱，病案资料记录不正确、不齐全、书写混乱等所致医疗纠纷非常常见，对医院、医师带来不良影响，也不利于司法鉴定和医疗技术鉴定的正常开展，基于此，规范病案管理非常重要。本研究探讨了病案管理中常见医患纠纷原因及预防方式，现报道如下。

1 资料与方法

1.1 一般资料

根据病案优化管理实施前后，选取2011年1月～2012年12月期间实施常规病案管理的我院200例病例资料，将其作为传统管理组。其中，200例病例资料来自内一科70例、内二科45例、骨科35例、康复科20例，外科30例。……