The following article comes from Lao Ye said medicine, the author Ye Zhengsong
On May 5, the administrative law enforcement of Yuhua District, Shijiazhuang City, issued the "Administrative Punishment Decision of Shijiazhuang People's Hospital", the details are as follows:
On February 5, 2024, the "Medical Accident Technical Appraisal" (Ji Yijian [2023] No. 006) on the medical dispute between Liang Moumei and Shijiazhuang People's Hospital transferred by the Hebei Provincial Medical Association concluded that this case is a first-class medical accident, and the doctor bears slight responsibility.
After preliminary review, the party's behavior is suspected of violating the provisions of Article 5 of the Regulations on the Handling of Medical Accidents, and an administrative penalty shall be imposed in accordance with law, and it is recommended that a case be filed. The case was filed on February 9, 2024.
It has been ascertained:
1. In the event of a first-class medical accident, the doctor bears slight responsibility;
2. The illegal facts of non-standard medical record writing are clear and the evidence is conclusive.
In the end, Shijiazhuang People's Hospital was given a warning and imposed an administrative penalty of a fine of 10,000 yuan.
See, although the medical prescription is slightly responsible, why do you still need administrative punishment?
One of the important reasons is that the writing of medical records is not standardized.
The non-standard writing of medical records is a common problem.
On the one hand, the management of medical institutions is not standardized, and on the other hand, it also reflects the weak awareness of legal risks of medical staff.
The writing of medical records shall be objective, truthful, accurate, timely, complete, and standardized.
Speaking of which, simple. But in reality, it's hard to do.
Last year, 14 medical staff in a hospital in Nanchang were warned and fined in accordance with the law. The reason for the punishment is that the medical records are not written in a standardized manner. During the two-year period from October 2020 to December 2022, physicians and nurses signed the names of other doctors and nurses in inpatient medical records; The physician failed to inform the patient's guardian of the treatment plan and treatment method and obtain his or her written consent as required.
In 2020, Dr. Song, the director of neurosurgery at a tertiary hospital in Henan, did not sign the informed consent form for surgery, nor did he sign the surgical record within 24 hours after surgery. Four months after the patient was discharged from the hospital, he found that his signature was missing when he copied the medical record and complained to the Zhengzhou Municipal Health Commission. The Zhengzhou Municipal Health Commission fined Dr. Song 15,000 yuan.
Dr. Song was not convinced, believing that the punishment was too severe, and sued the Zhengzhou Municipal Health Commission to the court. The court upheld the administrative penalty imposed by the Zhengzhou Municipal Health Commission. The reason is: doctors don't write medical records well, and this wind can't rise!
The Tangshan Municipal Health Commission also imposed administrative fines of 35,000 yuan and 50,000 yuan respectively on two hospitals in the district for irregular signatures of medical records.
Not only administrative law enforcement, but once a medical dispute lawsuit is initiated, it is even more passive.
According to the relevant provisions of the Tort Liability Law, the Basic Standards for Writing Medical Records, and the Law on Medical Practitioners, if the medical records are not standardized, there may be a civil legal risk that there is presumption of fault, which will put the doctor in a disadvantageous position in the trial of medical disputes.
There was a medical malpractice case in which a patient with advanced bowel cancer suddenly suffered cardiac arrest, and the doctor gave a verbal order to rescue the patient, and the intern wrote and signed the medical record on behalf of the patient after the patient died in the rescue.
Recently, there is a movie "Three Teams" based on real events, Zhang Yi and Li Chen. The film has a theme, which is norms, more than anything else.
Zhang Yi's master, an old police officer, became a vegetative person with a cerebral hemorrhage because of the pursuit of the suspect Er Yong. Just because he went home and drank half a glass of wine, he was not counted as a work-related injury, and he could only supplement his medical expenses by raising donations from colleagues.
Why?
Specification.
Writing medical records is a compulsory course for every doctor to step into the clinic, and it is also a requirement of medical quality management rules.
However, it must be confronted that there is a natural contradiction between a meticulous medical record and the limited energy of a clinician.
Major medical records, first trip, attending ward rounds, director rounds...... Repetitive medical record writing makes doctors seem to be turned into assembly workers in mechanized production. Therefore, pasting and copying against the template is naturally a helpless move under the saturation of workload.
However, from doctors who copy and paste medical records to mere formalities in medical record checks, it is not only the patients who take the risk, but also the doctors.
Every year, medical disputes and legal issues arise due to medical record writing and quality control issues.
How to balance the contradiction between the quality of medical record writing and the workload of doctors should be a topic that both Chinese and foreign medical institutions must strive to discuss.
I think the U.S. approach is pretty good.
In order to reduce the burden on doctors in writing medical records, the United States has implemented a medical record scribe system.
Scribes are trained in medical information management and assist physicians in keeping medical records in real time, helping physicians collect test results and communicate with referring physicians. For doctors, saves a lot of time.
It's not that medical staff don't punish if they make mistakes, and someone must pay for all mistakes. What's more, it is the medical care industry, where health is related and life is entrusted. I don't think there is a problem with the person responsible, but we have to find the problem from the root, and the shortage of clinical medical staff in most hospitals is the biggest problem!
A hospital, 1000+ employees, about 200 clinicians, less than 300 nurses, less than half of the total number of employees, tired to death, playing to death. Working overtime every day, without overtime pay, it is difficult to take a leave, and money will be deducted for leave. I still have to go to work during the New Year's holidays, and I have to work sick when I am sick, and I can't make mistakes. There is also a mandatory rest when driving, so you are not allowed to drive tiredly.
One doctor said that their department has 68 beds, and the number of inpatients is about 140 at its peak, and the corridor is crowded with extra beds like a refugee camp, and the total number of doctors and nurses is only 10. In this case, how can the medical record be written so exactly as a good embroidery needle on the ground?
If there are many cases of prostitution and prostitution, it means that the local economy is developed, and if there are many cases of robbery and theft, it means that the local economy is in decline.
If there is no reason for a medical worker to make a mistake that should not be made, it really should not be done, and it should be punished.
However, if we do not carefully investigate the causes, trace back to the source, find out the pro-enzyme factors that make mistakes and violations, lack of care for them, and just blindly punish them, regardless of the consequences of the causes, this is not to make up for the sheep, but to make mistakes.
Because even if this punishment is severe, there will be the same violations and mistakes in the future.
The 18 core safety management of medical quality is not only a matter for clinical medical staff, but also a comprehensive and comprehensive issue for hospitals.
No, it is obviously a problem of comprehensive management of the hospital, but it turns out that the leadership will never be wrong, the administration will never be wrong, only the clinical error, it is their own problem. The board just hits them.
-THE END-
Source: Lao Ye said medicine