Common Problems and Countermeasures of Doctor-Patient Communication Record. (March 2014)

• Record Type: Journal Article
• Authors: Han, Yichao; Peng, Ye; Yang, Xiufang; Xie, Na
• Is Part Of: Chinese medical record. Volume 2:Number 1(2014:Jan.)
• Page Start: 37
• Page End: 40
• Publication Date: 2014-03
• Subjects: Medicine -- China -- Periodicals; 610.951
• DOI: 10.3109/23256176.2014.897503
• Languages: English
• ISSNs: 2325-6176

Abstract

<abstract> <title>Abstract</title> <p> <italic>Objective</italic>. To regulate the doctor-patient communication record, reduce defects and errors in doctor-patient communication and reduce the occurrence of medical disputes, so as to guarantee the quality of medical treatment. <italic>Method.</italic> Randomly selecting 585 terminal medical records of January 2013 in our hospital, performing quality control checks on the doctor-patient communication records in the medical records, recording the effects of quality control in Excel and performing statistical analysis. <italic>Results.</italic> Of the 585 medical records, 180 medical records have defects in the doctor-patient communication record, the defect rate is 30.77%, there are a total of 199 defects altogether, the commonly occurring defects are as follows: incomplete general information of a patient (10.94%); incomplete or simple communication content (6.15%), absence of corresponding doctor-patient communication record such as the absence of the automatic discharge conversation record or informed consent for blood transfusion and blood product (5.98%), and communication record signed by an unauthorized person (3.07%). <italic>Conclusion.</italic> Strengthening the sense of responsibility of doctors, strengthening the effective doctor-patient communication and regulating the doctor-patient communication record can effectively prevent the occurrence of medical disputes.</p> </abstract>