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目的调查医疗告知文书患方签署情况,查找问题所在,提高医疗告知文书的质量。方法回顾性调查2011年1月出院病案9635份中的医疗告知文书患方签署情况,包括知情同意书和委托书。结果对病情、手术、操作有告知的病案7521份,患者本人签署1178份,患者亲属签署1124份,正确签署2302份,合格率30.61%。医师如果能正确指导患方正确填写告知文书,杜绝漏项,正确率可以提高到87.71%。由表格设计繁琐造成了43.66%的不合格率。结论合理设计医疗告知文书表格,增加可操作性;对医师进行法律知识的培训,增加法律意识;定期检查,及时发现问题,及时改正是提高医疗告知文书患方签署质量的有效方法。
Objective To investigate the signatures of patients in medical notification documents, find out the problems and improve the quality of medical notification documents. Methods A retrospective survey was conducted on the signing of medical notification documents among 9,635 discharged medical patients in January 2011, including the informed consent form and power of attorney. Results There were 7521 cases of illness, surgery and operation, 1178 were signed by the patients themselves, 1124 were signed by relatives of the patients, and 2302 were correctly signed with a pass rate of 30.61%. If the doctor can correctly guide the patient to fill out the notification documents correctly, to prevent omissions, the correct rate can be increased to 87.71%. Tedious form design caused 43.66% of the failure rate. Conclusion It is an effective way to improve the signing quality of medical notification instruments by reasonably designing the medical notification form and increasing the maneuverability. Training doctors to legal knowledge and increasing legal awareness.