The implementation specification of this 180 page was formulated and promulgated by the Health Department of Jiangxi Province. The Trial Regulations not only standardized the writing format of medical records in detail, but also clearly defined some vague problems in previous medical records. In addition to medical records, the contents and formats of 39 medical notification documents were specified in detail for the first time. If doctors write medical records, the names of diseases will not be mixed; Simplified characters and abbreviations in foreign languages shall be written in accordance with state regulations and international practices, and shall not be created arbitrarily; All kinds of paid or expensive examination, treatment, surgery, blood transfusion or self-funded drugs must be approved by patients or relatives before implementation; The doctor's signature should be written at the bottom right of the medical record, and the full name should be signed in block letters, and the handwriting should be clear and legible.
The "Specification" also specially added "prescription writing requirements", stipulating that the prescription of narcotic drugs should be used by doctors or anesthesiologists with technical titles above the attending physician, and the words signed by doctors with the right to prescribe narcotic drugs should be reported to the health administrative department for the record in addition to the pharmaceutical department and the medical department; Drug names should be written in chemical names, and a drug cannot be written in two languages at the same time; The dosage of drugs on prescriptions shall be written in Arabic numerals, and the unit of drug dosage shall be the national legal unit of measurement; Prescriptions of toxic and narcotic drugs should be prescribed according to regulations, and the unit or address of the patient should be recorded; Prescriptions for the use of psychotropic drugs shall not be written on the same prescription as ordinary drugs.
Jiang Guoping, director of the Department of Medical Affairs of Jiangxi Provincial Health Department, said that standardizing the writing of medical records is not only to let patients know their illness and medication, but also to better protect the legitimate rights and interests of both patients and medical staff. This standard will have an important impact on the handling of medical disputes and medical research.
Core tips
The doctor told the illness truthfully, and the old lady was "scared to death".
How to protect patients' right to know is appropriate and legal?
typical case
The doctor said that the old lady was "scared to death" of this disease.
Mrs. Wang in a city in Jiangsu was sent to the hospital for examination by her children because of her physical discomfort. She didn't want the old lady to be "scared to death" after learning about her illness. In addition to leaving a lot of pain for her children, it also triggered a medical dispute.
In August 2004, Mrs. Wang found a lump in her chest and went to a hospital in the city for examination under the arrangement of her child. After being diagnosed as a malignant tumor by the hospital, the doctor advised Mrs. Wang's family to have an operation immediately, but did not tell Mrs. Wang about her illness. Mrs. Wang was admitted to the chest and heart surgery department of the hospital and prepared for elective surgery.
Soon, the hospital will operate on Mrs. Wang. An anesthesiologist said to Mrs. Wang during the preoperative examination, "You are very ill and need to have a thoracotomy at once." You should be mentally prepared. " Unexpectedly, Mrs. Wang, who had never known her illness, suddenly fell to the ground with a splash and was unconscious. Emergency personnel arrived quickly and immediately sent Mrs. Wang to the emergency room for rescue. After about 90 minutes of rescue, Mrs. Wang died of sudden cardiac death, and the rescue was invalid.
Mrs. Wang's sudden death left her children at a loss. They agreed that "the doctor should not tell her about her illness like this." The old lady has a bad heart. How can a doctor tell a patient about his illness without considering his physical condition? " Therefore, it is concluded that the old lady was "scared to death" after the doctor revealed her illness, and the court of appeal asked the hospital to bear legal responsibility.
Mrs. Wang's family said: "The patient's condition is really serious, but it is entirely possible to recover through surgery. Hospitals can't tell patients the truth on the pretext of not infringing their right to know, regardless of their acceptability, which leads to tragedies, and hospitals are responsible for improper information. In order to avoid the trouble caused by' not telling', the hospital caused accidents to patients, which also violated the purpose of the hospital to save lives. "
The hospital believes that "Mrs. Wang suffers from malignant tumor and is in poor health. After learning about the condition, she induced cardiogenic heart disease and died suddenly, and was not intimidated. " Anesthesiologists inform patients of their illness in order to make them psychologically prepared during the operation and to protect their right to know. It is reasonable and legal for the hospital to inform the patient of the condition and the content of the operation before performing major surgery on the patient. So the hospital should not bear any responsibility. "
Patient statement
How can you tell the condition of a critically ill patient at will?
In view of the above-mentioned disputes between doctors and patients, the topic of patients' right to know has once again attracted people's attention.
The reporter made an investigation for this. In the outpatient halls of several general hospitals such as Guangzhou Zhongshan First Hospital, Guangzhou Twelfth Hospital and Guangzhou Air Force Hospital, the reporter interviewed some patients who came to see a doctor at random. For the situation in the above cases, the vast majority of respondents said that it is certainly impossible to inform seriously ill patients with heart disease, such as Mrs. Wang, whether there are rigid regulations in the hospital or not.
In the outpatient hall of the First Hospital of Zhongshan, Mr. Song, a citizen who came to see a doctor, said: "I think the old lady must have been scared to death. Even if she died of a heart attack, it was because an anesthesiologist's words induced the old lady to have a heart attack. If I were an old lady's child, I wouldn't accept such a thing. Why didn't your doctor just tell the children about the illness? We young people can't stand such a thing sometimes, let alone an old man. "
Chen Bing, who lives in the Air Force Hospital, is a little excited. "This kind of thing is more unacceptable than medical malpractice. To tell the truth, doctors should protect patients' right to know, but it also depends on what kind of people they can tell their children and their families, so that they can choose whether to tell patients. Who heard that he was seriously ill and couldn't jump? "
Chen Bing told the reporter an incident of his friend. "A friend of mine who has passed away was found to have a benign tumor in his body during an examination before his death. The doctor didn't tell him at that time, but told his wife. Under the doctor's treatment, his condition recovered quickly. After leaving the hospital and going home for some time, he decided to go to the hospital for a second examination, but he went to another hospital. The doctor in this hospital told him after reexamination that' your tumor has recovered quickly and it seems that the treatment effect is good'. When a friend heard that he had a tumor, he couldn't accept it at once and couldn't listen to the doctor's explanation any more. From then on, I was disheartened and unhappy, and I didn't want to receive any more treatment. In less than a year, the benign tumor finally became a malignant tumor, and he passed away in depression. "
Chen Bing finally said: "If the doctors in the Second Hospital don't say so, maybe my friend will be fine." 34106ed194a71f00e Medical Economic News
In the reporter's subsequent interview, only a few people thought that doctors should inform patients of their illness in time. Miss Chang believes that everyone's personality and psychological endurance are different. This method of concealing the true condition is not suitable for all cancer patients. The so-called white lies may sometimes bring endless regrets.
Hospital practice
Cautious notification is the embodiment of humanized service
An insider believes that in theory, telling patients about their illness is really to protect patients' right to know. In an interview with reporters, a hospital administrator said, "The hospital has clear regulations on this, and doctors should abide by them."
Mr. Cao from the Medical Department of Jiujiang Maternal and Child Health Hospital in Jiangxi told the reporter, "The general condition does not need special instructions from the hospital. Doctors will definitely choose to inform patients in time, because this will help patients to cooperate with treatment. Moreover, according to Article 62 of the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions,' medical institutions should respect patients' right to know about their illness, diagnosis and treatment'. Article 26 of the Law on Medical Practitioners also clearly stipulates that doctors should truthfully introduce their illness to patients or their families. "
However, Mr. Cao also said, "Considering some serious diseases or serious diseases that are life-threatening, we will also inform the patients' families in the form of' special case notice' according to the hospital's' protective medical care' measures, and inform the patients of the truth when taking protective medical care, and start treatment after receiving a clear reply and signature from the patients' families."
Lawyer Cao also told reporters that at present, some requirements of relevant laws and regulations on this form of illness notification are vague and there is no fixed practice mode. Hospitals have to formulate hospital rules and regulations from the perspective of protecting themselves and avoiding misunderstandings of patients, so as to avoid medical disputes as much as possible.
A person in charge of the medical education department of the First Affiliated Hospital of Henan University also told the reporter: "The hospital is very cautious when telling some critically ill patients about their condition. We have witnessed many such disputes between doctors and patients, and sometimes it feels worse than dealing with medical accidents. Our hospital has always emphasized psychological intervention for patients, which actually has a great influence on the recovery effect of patients' condition. When we meet a critically ill patient, we express the patient's condition to the patient's family as accurately as possible and discuss with them how to inform the patient himself. In fact, this is also a manifestation of humanized service in hospitals. "
Lawyer's statement
Proper notification is an extension of the protection of the right to know.
Should the hospital bear the responsibility for the above cases? The reporter specially consulted the legal experts dealing with medical accidents.
Lawyer Chen Zhihua, director of the Medical Malpractice Committee of Beijing Lawyers Association, believes that this is an inconclusive dispute between doctors and patients. According to the basic principles of existing laws and regulations, doctors do have the responsibility to inform patients of their illness, that is, to protect patients' right to know, but they should also avoid affecting patients.
Chen Zhihua said: "The existing laws and regulations have no clear requirements on how to deal with the medical risks caused by patients' self-disclosure. Therefore, I think we should re-examine and attach importance to the operability of the guiding laws and regulations in the current national laws and regulations to deal with such cases, otherwise such disputes will never have results and may be unfair to both doctors and patients. "
Song Zhongqing, a senior lawyer who specializes in handling medical disputes in Shandong leading law firm, said: "Whether to bear legal responsibility depends on whether there is a direct causal relationship between the old lady's death and the doctor's illness. If so, then the hospital will certainly bear part of the responsibility; If not, the hospital is not responsible. "
Song Zhongqing said: "Because patients may die of other normal causes during hospitalization, not all patients died of the fault of the hospital. This is not up to anyone, and the relevant judicial expertise shall prevail. The old lady's death after "rescuing for about 90 minutes" also depends on whether there are medical malpractice factors. Therefore, both doctors and patients can conduct medical accident identification, and the responsible person can be identified through the identification results. "
Song Zhongqing also believes that patients' right to know is not only to inform patients and their families about their illness. Article 62 of the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions stipulates: "Medical institutions should respect patients' right to know about their own illness, diagnosis and treatment. In the implementation of surgery, special examination, special treatment, should make the necessary explanation to the patient. If it is not appropriate to explain the situation to the patient because of the implementation of protective medical measures, the patient's family should be informed. " When some risks that may occur in the patient's treatment plan need to be signed by the patient and his family, the hospital should clearly explain them, otherwise the hospital should bear certain legal responsibilities for the damage caused.
A legal person from Guangdong Junxin Law Firm believes that patients have the right to know the true information about treatment, which is also the duty of doctors. No matter the advantages or disadvantages of treatment behavior, doctors should introduce patients truthfully and objectively, without any cover-up. He said that the Regulations on the Handling of Medical Accidents stipulates that "in the process of medical treatment, medical institutions and their medical staff should truthfully inform patients of their condition, medical measures and medical risks. , and answer the consultation in time; However, adverse consequences for patients should be avoided. " The Law on Medical Practitioners also provides for this.
This has two meanings: first, hospitals must ensure patients' right to know; Secondly, hospitals should pay attention to ways to ensure patients' right to know, so as to avoid adverse consequences. Under some special circumstances, medical staff can choose appropriate time or method to avoid adverse effects on patients' treatment and rehabilitation, or introduce their illness to their close relatives, which is regarded as an extension of patients' right to know.