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目的探讨创伤外科病历书写与纠纷的防范,减少和避免纠纷的发生。方法对近5年来因外伤入院并导致医疗纠纷的41份病案进行回顾性分析、总结。结果严格的病历书写能有效减少创伤外科医疗纠纷的发生。结论在创伤外科医疗活动中,应建立健全完善的病历书写管理制度,医务人员规范自己的病历书写,能有效防范医疗纠纷的发生。
Objective To investigate the prevention and treatment of traumatic surgical records writing and disputes and to reduce and avoid the occurrence of disputes. Methods Retrospective analysis and summarization of 41 medical records of medical disputes caused by trauma admitted in the recent 5 years were summarized. The results of strict medical records can effectively reduce the incidence of trauma surgical medical disputes. Conclusion In the traumatic surgery activities, a sound and complete medical records management system should be established. Medical staff should standardize their own medical record writing and effectively prevent the occurrence of medical disputes.