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目的查看调查归档病案中签名存在的缺陷,分析原因,提出处理措施。方法通过对某市9家医疗机构857份归档病案抽查,主要查看缺陷的类型及频次。结果缺陷病案642份,缺陷率达74.91%。病案首页无医务人员签名572次,手术相关文书中无手术者签名198次,病历中无医师签名152次、无护士签名66次,辅助检查报告单无医师签名144次、圆珠笔签名89次,无患者签名27次,患方无效签名135次。结论规范的签名与医务人员规范病历书写意识、重视签名程度、提高法律意识及加强科室质控相关。
Objective To investigate the shortcomings of the signatures in the archives filed for investigation and analysis, analyze the reasons and put forward the handling measures. Methods A total of 857 archival medical records were collected from 9 medical institutions in a city to find out the types and frequency of defects. The results of 642 defect cases, defect rate of 74.91%. There were 572 medical signatures without medical staff signature, 198 signatures without surgery, 152 physician signatures without medical records, 66 signatures without nurses, 144 physician signatures with aided examination report, 89 ballpoint pen signatures, none Patient signature 27 times, the patient invalid signature 135 times. Conclusion The normative signature is related to the standardization of medical records by medical personnel, the importance of signature, the enhancement of legal awareness and the enhancement of quality control in departments.