Medical "blood case" dispute caused by an electronic medical record

The core reminder of the electronic enthusiast network : With the development of medical informatization, the traditional medical model is gradually being replaced by informationized medical behavior. In September 2010, the Ministry of Health issued a notice requesting some hospitals and regions in the country to carry out pilot work on electronic medical records. The emergence of electronic medical records not only broke the dilemma of "time-consuming handwriting", but also solved the difficult problem of "Tianshu medical records" difficult to identify, and became the focus of discussion in the past two years. But what is worrying is that the disputes between doctors and patients caused by it are increasing. From January 2011 to September this year, the Nanchang Court of Wuxi City has accepted a total of 30 cases of doctor-patient disputes, of which the electronic medical record involved rate is as high as 85%. The various issues highlighted in the dispute cases deserve our careful consideration.

Management is not standardized

Nanchang Court Litigation Service Center, an emotional party is going through the filing procedures. The person's name is Chen Su. From January this year, her old father, who was over 70 years old, began to feel poor breathing, and occasionally saw blood after coughing. At the suggestion of her colleagues, she took her father to the hospital for registration. "The doctor asked my father's physical condition, and after doing a lot of tests, it turned out that it was advanced lung cancer." Chen Su said, "On April 5, the hospital performed an operation for my father. Not two days after the operation He passed away! "The huge grief made Chen Su unbearable, which in turn made her question the doctor's treatment. After thoroughly reviewing her father's medical records, she came to the court with anger and asked the judge to help her to do justice, allowing the hospital to compensate medical expenses, death compensation, funeral expenses, etc., totaling RMB 220,000.

Chen Su told the judge that the paper medical records she received were all printed directly by the hospital. The temporary medical order on the day of her father's death clearly showed chaotic chronological order. "The rescue started at 9:10, but according to the medical record, the director of the department Wang Lin gave the rescue doctor 20 minutes after the rescue, which is almost self-mouthing." Chen Su suspected that her father's death was not rescued by the hospital. Caused in time. The hospital representative explained in court that at the time, in order to gain time, the oral medical order was executed during the rescue, and the written medical order was replenished afterwards, which caused the time confusion in this record. In this incident, the doctor responsible for the input of information was not rigorous enough, but Wang Lin was indeed the doctor's order before the rescue began, and there was no situation where the hospital was not rescued in time.

The presiding judge of the case told reporters that in the increasingly tense relationship between doctors and patients, a slight error of medical workers may become the target of questioning by patients and their families, and the credibility of medical units is facing an unprecedented test. "The time is not entered in time, the number of doctors is mixed, and the electronic signature of Zhang Guanli Dai. These subtleties reflect the lack of management of electronic medical records in the hospital." The judge said, "These may lead to the authenticity of patients' medical records, The question of reliability. "The judge believes that the occurrence of such disputes has a certain positive significance from the dialectical point of view. As a provider of electronic medical records, medical units should be more meticulous and patient in the input of information and stricter and more cautious in the management of medical records. The hospital can do all it can to turn pressure into motivation, while improving the quality of business while reducing the patient's distrust of the hospital.

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