內容目錄
According to the administrative punishment results issued by the Wenzhou Municipal Health Commission of Zhejiang Province, on February 25, the Second Affiliated Hospital of Wenzhou Medical University (hereinafter referred to as: Wenzhou Medical University Second Affiliated Hospital) Hospital) for failing to fill in the medical records as required, and was warned by the local health and health commission and fined 12,000 yuan.
According to the “Decision on Administrative Penalty”, the Second Affiliated Hospital of Wenzhou Medical University The act of not signing and confirming the relevant ward round records of the patient violated the “Regulations on the Prevention and Handling of Medical Disputes”, and the Wenzhou Municipal Health Commission decided to give the hospital an administrative penalty of a warning and a fine of 12,000 yuan.
The hospital official website shows The Second Affiliated Hospital of Wenzhou Medical University, also known as Yuying Children’s Hospital Affiliated to Wenzhou Medical University, was founded in 1976. Its predecessor was the Bethune Outpatient Department of Wenzhou Medical College. The School of Clinical Medicine has 1 national key clinical specialty, with three campuses in Lucheng, Oujiangkou and Longwan, with 3,401 beds actually open. In the comprehensive ranking of Chinese hospital science and technology value, it ranks 85th.
Major hospitals “go wrong” on medical records span>
Xu Yucai, former deputy director of Shanyang County Health Bureau, Shaanxi Province, believes that , Medical records, as legal medical documents, are an important basis for medical disputes and lawsuits, and can also become the umbrella of medical staff at critical times. Therefore, the standardized writing of medical records is particularly important.
However, there are still many medical institutions that “step on the thunder” one after another. There are many tertiary hospitals.
At the end of 2021, according to the Taian Municipal Health Commission, Taian Feicheng Traditional Chinese Medicine The hospital was warned and fined 20,000 yuan by the local health commission for failing to fill in the medical records as required. The hospital is a tertiary first-class traditional Chinese medicine hospital.
September to November 2021, less than two months, Hebei The Third Hospital of the Medical University received three “tickets” in succession due to irregular medical records, with a fine of 60,000 yuan.
In May 2021, Yingtan City People’s Hospital also suffered from irregular medical records. , was warned and fined 20,000 yuan.
The medical record must not be written sloppily, not even a single word can be wrong, “Local anesthesia” “It was written as “general anesthesia”, and some hospitals were fined.
The Fourth People’s Hospital of Datong City was diagnosed with misoprostol on the prescription The dosage of the tablet is inconsistent with the prescribed dosage of the drug insert and the actual dosage of the patient; the anesthesia method “local anesthesia” recorded in the temporary doctor’s order, the course of the disease, and the informed consent for the operation is inconsistent with the preoperative discussion and the “general anesthesia” in the operation record, etc. Filled out the medical records as required, was warned and fined 20,000 yuan.
If you do not write medical records properly, the consequences are very serious
“Writing medical records” Can it be cured?”
“Writing medical records is formalism. ”
In the eyes of some doctors, medical records are trivial, and it is a waste of time to write medical records time. Many medical institution managers do not realize the importance of medical records.
Actually, Peking Union Medical College Hospital has “three treasures”: professors, medical records, library. It is precisely because of these “three treasures” that its talents are produced in large numbers and passed on from generation to generation. Xiehe medical records are rich in content, rigorous and detailed, and have always been praised by peers.
It is reported that medical records are an important basis for diagnosis and treatment of patients, and the first part of scientific research. The first-hand clinical data is also the face of the doctor, which more directly reflects the medical quality, academic level and management level of a hospital.
Standardized medical record writing, preservation, management is also preventive and medical treatment The Key to Disputes
《Guangzhou Court Medical Disputes The white paper (2015-2017) of Litigation Situation shows that the verdict found that the medical party was negligent mainly reflected in the failure to fulfill the obligation to inform and explain, the diagnosis and treatment behavior was not in line with the medical level at the time, and the writing and management of medical records were not standardized, and the autopsy was not prompted. .
In which medical record writing, medical record management and judging whether the doctor It is closely related to the fulfillment of the obligation of notification and explanation and whether the diagnosis and treatment activities are in line with the medical technology level at that time. Medical records are the key materials for medical damage identification; if medical records are forged, tampered with, or destroyed, it may be presumed that the doctor is at fault without the need for identification; if medical damage identification is affected by flaws in the writing of medical records, the doctor shall bear the adverse consequences.
Defects in medical record writing and modification are mainly reflected in medical record writing errors and scribbled handwriting. Identification, omission of signature, wrong date, modification not in accordance with specifications, omission of records or simple records, inconsistent records, electronic medical records that do not conform to specifications, etc.
The poor management of medical records is manifested as missing checklists, imaging data, outpatient medical records, etc. Medical record information, refusing patients to view medical records in real time, delaying copying for patients, sealing medical records, etc. The above-mentioned flaws in the writing of medical records and poor storage often arouse strong doubts from patients, induce disputes, and intensify conflicts between doctors and patients.
This problem is particularly prominent in the field of social medical care.
When talking about strengthening the medical quality and safety of social medical institutions, a Shanghai Health administrators have publicly stated, “In 2019, the Shanghai Medical Malpractice Appraisal Center accepted 300 cases of medical malpractice appraisals. The medical history of the society is outstanding, and the medical history records are incomplete. The lawsuit will definitely lose a lot.”
Regulations on the Supervision and Administration of the Use of Medical Insurance Funds stipulate that medical records such as medical records are not only proof of medical The “certificate” and “basis” of the authenticity of the service are also the “certificate” and “basis” for medical insurance payment, and also the “certificate” and “basis” for medical insurance supervision and inspection to determine whether there is “violation” in medical services.
If there is a problem with the medical records, it may be considered that medical services are fraudulent, May have to bear the refusal of medical insurance or even be identified as fraudulent insurance, bear legal responsibility.
Xu Yucai said that for medical institutions, medical records are proof that they have not done important evidence of wrong, so it must be both written and managed. If there is a problem with the medical records, it may be considered that medical services are fraudulent, and the medical insurance may refuse to pay or even be identified as fraudulent insurance, and bear legal responsibility.
Source: Look at the Yangtze River Delta, Medical Reform span>
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