论文部分内容阅读
麻醉文书是整个医疗文书的重要组成部分,是医疗纠纷中的重要法律依据。麻醉文书主要包括麻醉前访视单,麻醉知情同意书,麻醉记录单,麻醉医嘱单,麻醉后访视单和麻醉收费单。麻醉前访视单反映了麻醉医师对患者病情的了解程度;麻醉知情同意书是麻醉医师与患者及其家属进行了充分沟通的证据;麻醉记录单要反映整个麻醉过程的详细情况;麻醉医嘱单必须有至少两人审核执行;麻醉后访视单要反映患者在麻醉后的恢复情况;正确书写麻醉文书对防范医疗纠纷,提高教学和科研质量有着十分积极的意义。
Anesthesia instruments are an important part of the entire medical document and an important legal basis in medical disputes. Anesthesia documents include pre-anesthesia visit sheets, consent for anesthesia, anesthesia record sheets, anesthesia order sheets, post-anesthesia visit sheets and anesthesia fee sheets. The pre-anesthesia visit sheet reflects the anesthesiologist’s knowledge of the patient’s condition; informed consent is the evidence that the anesthesiologist has communicated adequately with the patient and their family members; the anesthesia record sheet should reflect the details of the anesthesia process; the anesthesia order At least two people must be audited and enforced. A post-anesthesia visit should reflect the recovery of patients after anesthesia. Correct writing of narcotic instruments is of great positive significance in preventing medical disputes and improving the quality of teaching and research.