Analysis on Related Problems of A Public Hospital Court Judgment
Objectives To analyze the specific categories and incidence of medical record problems in medical dispute court judgments and the correlation between medical record related problems and the judgment of whether medical institutions are liable when the court decides responsibility,so as to classify the high litigation risk points of medical records and propose measures to improve the quality control of medical records.Methods 125 cases of court judgments received by a public hospital during the 6-year period from January 1st,2017 to December 31st,2022 were included in this study.The medical records with medical record defects proposed by patients,appraisal institutions and courts in the judgments were analyzed by stratification,including the subject of the lawsuit to question the medical case,and the types of hospitalization and medical record problems.Results Among the 125 cases of court judgments received by a public hospital from 2017 to 2022,there were 73 cases of defective medical records.The problems mainly focused on the authenticity,completeness,accuracy and quality of medical records.The problems of outpatient medical records mainly include missing medical records(31.03％),insufficient risk notification(27.59％),inadequate follow-up(17.24％)and errors(7.24％).The problems of inpatient medical records were concentrated in insufficient risk notification(44.07％),connotation and quality of medical records(27.12％),sealing of medical records(6.78％),error of inspection report(6.78％)and authenticity and timeliness of medical records(6.78％).In this study,no statistical difference was found between whether there was a problem in the medical record and whether the court decided that the medical institution was responsible.Conclusions From the legal point of view,in order to protect the rights and interests of the medical side,medical records as an important basis for litigation,medical institutions should still pay attention to the standardization of writing medical records.It was suggested to strengthen the training of writing medical records from the perspective of litigation risk,build a comprehensive quality control system from the perspective of improving the connotation and quality of medical records,and improve the storage mechanism of medical records from the perspective of the integrity of medical records.
NETL
NSTL
万方数据
