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关于手术知情同意实施现状的分析研究OACSTPCD

Analysis and research on implementation status of informed consent in surgery

中文摘要英文摘要

目的 通过调查手术知情同意书内容和签字情况、授权委托书签署情况,了解目前医疗机构关于手术知情同意的落实情况.方法 采用分层随机抽样法抽取了某三甲医院 2022 年度上半年的 276 份手术病历,并就手术同意书和授权委托书签署情况进行分析.结果 医患双方的签字比较规范;医方关于术前主要诊断、手术名称、术中或术后可能出现的并发症、手术风险告知比较充分,对患者自身存在的高危因素、替代治疗方案及其利弊的告知存在不足;非患者本人签字的手术同意书,授权委托书签署不规范.结论 医疗机构手术知情同意落实较好,但仍存在一定缺陷.医疗机构可通过加强法律法规培训,明确授权范畴、强化术者告知、签字和落实监督检查等方面来保障知情同意的落实,切实保障医患双方权利和义务的统一,有效规避医疗风险,促进和谐医患关系的构建.

Objective:Investigating the content and signing status of the informed consent form for surgery,as well as the signing status of the power of attorney to understand the current implementation of informed consent for surgery in medical institutions.Methods:A stratified random sampling method was used to investigate the signing status of surgical consent and power of attorney on 276 surgical records from a tertiary A hospital in the first half year of 2022.Results:The signatures of both patients and doctors were relatively complete.The medical teams had provided sufficient information to patients regarding the main preoperative diagnosis,surgical name,possible complications during or after the surgery,and surgical risks.However,there was inadequate information on the patient's own high-risk factors,as well as alternative treatment plans and their advantages and disadvantages.The signing of surgical consent and power of attorney signed by non-patients was not standardized.Conclusion:The implementation of informed consent for surgery in medical institutions is relatively good,but there are still some shortcomings.Medical institutions can ensure the implementation of informed consent by strengthening legal and regulatory training,clarifying the scope of authorization,strengthening the surgeon's notification and signing,as well as implementing supervision and inspection,so as to protect the unity of rights and obligations of doctors and patients,effectively avoid medical risks,and promote the construction of a harmonious doctor-patient relationship.

马桂清;严金海

南方医科大学卫生管理学院,广东 广州 510515南方医科大学通识教育部,广东 广州 510515

手术同意书知情同意授权委托

consent form in surgeryinformed consentauthorization and delegation

《中国医学伦理学》 2024 (002)

163-167 / 5

10.12026/j.issn.1001-8565.2024.02.07

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