A 24 -year -old man died suddenly after 5 days!The entire process of the restoration of the electronic medical records saved this private secondary hospital 丨 medical view

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A 24 -year -old man died suddenly after 5 days!The entire process of the restoration of the electronic medical records saved this private secondary hospital 丨 medical view

2022-05-15 06:11:55 4 ℃

Guide

Emergency, emergency pain, emergency risk is really outrageous.

Author: Running Emergency Lao Liu

This article is published by the author's authorization of the medical pulse. Do not reprint without authorization.

Signing and refusing to be diagnosed and leaving the hospital, the hospital will also have to pay for the death hospital in the future.

Emergency, emergency pain, emergency risk is really outrageous.

Retrospective

The patient, 24 years old, was visited at 23 o'clock at night for "chest tightness and chest pain 4 hours" at 23 o'clock at night. In the early morning of the next day, the patient took the medicine and went home to rest. In the early morning of 5 days, the patient died of chest tightness and chest pain, and suddenly died suddenly in a hotel lobby.

The Public Security Bureau's investigation conclusion: conforms to sudden death. The patient did not check the corpse, and the appraisal center conducted a legal identification of the corpse, and the identification concluded was in line with sudden death.

Patients' parents believe that in the case of the CT report and electrocardiogram, the patients did not let the patient hospitalize and do not be further diagnosed. Instead, they were advised to take the medicine home to rest. Patients did not fulfill their diagnosis and treatment obligations during the medical clinic diagnosis and treatment, which eventually caused the patient to die. The later appealed to the court and asked the medical party to compensate for the loss of more than 578,000 yuan.

The medical side said that there was no error in diagnosis and treatment:

1. Patients have insufficient blood supply to the heart. The doctor explains the condition to the patient, and twice suggested that further examination and infusion and hospitalization. The patients refused and requested oral drug treatment.

2. The first diagnosis doctor prescribed the drug in line with the patient's symptoms. The diagnosis and treatment behavior conforms to the routine.

3. Patients twice refused medical diagnosis and treatment suggestions, and did not cooperate with diagnosis and treatment. The doctor told him to be hospitalized as soon as possible. The patient expressed his understanding of the content and left the hospital by himself.

4. Patients, as those with complete civil behavior, are responsible for their actions when they are diagnosed, and they are in response to their actions. Moreover, there are many factors that cause sudden death.

5. The patient did not test the patient's body, the cause of death was unknown, and the foundation of pathological identification was lacking.

Therefore, the diagnosis and treatment behavior of the medical prescription is in line with the routine, without illegal acts, no infringement, and no fault. The patient has not been damaged during the diagnosis and treatment. It can be seen from the common sense. responsible for damage repairs.

During the trial, the court retracted the background database of the electronic medical record system of the medical clinic. Search in the background database of the clinic, and only found a set of related clinic information. The time was retrieved from 23:09 to 00:17 the next day. One copy of each, a total of 4 pages.

The medical system mechanism is set to: within 24 hours of registration, a doctor can log in to the doctor's account with the password to open the checklist, prescribe the prescription, create and modify the diagnosis, outpatient medical records; Paper medical records can no longer modify data.

After comparing the data content of the registered system and the outpatient electronic system, it was not obtained from other operating traces outside the outpatient electronic medical record operation record log.

The outpatient medical records showed that patients with chest tightness, chest pain, no dizziness, headache, nausea, and breathing difficulty occurred 4 hours ago, and the symptoms lasting for about 5 minutes were relieved. In the past, health, no chronic medical history; admission to the hospital: BP 120/50mmHg, God's clear language, good spirit, entered the clinic, checked and cooperated; Wet Luo Yin, heart rate 96 times/minute, rhythm, not heard of the auspicious area of ​​each valve, and pathological murmicals, soft abdomen and no tenderness and reflection pain, no edema in both lower limbs, and normal limbs.

Emergency chest and abdomen CT reminds: Consider the large lung alveolar, indicate the expansion of the abdominal and intestinal tube. Electrocardiogram icon: abnormal electrocardiogram, left ventricular hypertrophy, ST-T change. It is recommended that blood tests, blood routine, and myocardial infarction, and patients refuse. It is recommended that the symptomatic infusion and hospitalization are recommended, and the patient still refuses and requires the treatment of medication. The patient was hospitalized as soon as possible, and the patient expressed his understanding and then left the hospital himself. Prescription aspirin, single -nitrate pearl ester, compound Danshen drop pill, and die meta silicon oil tablets orally.

Case appraisal

The appraisal center conducted an appraisal of this case based on the medical records retrieved by the court, and issued the "Judicial Appraisal Opinions" to point out:

1. Patients with chest pain and chest tightness, the medical party gives ECG and chest CT examination to confirm the insufficient blood supply to the myocardial muscle. Except for other diseases that cause chest pain, it is recommended that patients with three tests of myocardial enzyme spectrum and myocardial infarction. It is recommended to be hospitalized. The above diagnosis and treatment behavior is in line with the Chinese Medical Association's "Guidelines for Diagnosis and Treatment of Cardiovascular Avioralians".

2. Regarding informed informedness: During the diagnosis and treatment of patients, the medical prescription is recommended for patients with three tests of myocardial enzyme spectrum and myocardial infarction. It is recommended that patients in hospital treatment. In the process, there are insufficient communication. When the patient refuses to diagnose and treat the diagnosis and treatment, it is not signed when the patient refuses to sign the diagnosis and treatment. Knowing consent, there are flaws in the diagnosis and treatment behavior.

3. Writing about outpatient medical records: Article 2 of the Ministry of Health's "Regulations on Medical Division Management of Medical Institutions" refers to the sum of text, symbols, charts, images, slices and other materials formed by medical staff during medical activities, including doors (including doors Urgent) Diagnosis and hospitalization. Article 4 If there is a cardiac (urgent) diagnosis and medical record file in a medical institution, the diagnosis calendar of the door (urgency) is kept by the medical institution; if there is no file (urgent) diagnosis and medical record file in the medical institution The medical records are kept by the patient. Although the medical prescription was written in detail during the patient's diagnosis and treatment process, he did not build a file for the patient, did not give him a certificate, and did not hand it over to the patient's custody, so that the patient and family members did not attach enough attention to their own diseases. 4. Review materials found that the medical records of medical records are not standardized: on the electrocardiogram report, there are no basic information such as the patient's name, gender, and age. In the writing of outpatient medical records, although there are insufficient myocardial blood supply, alveolar, and flatulence diagnosis, it is recommended to further examination and hospitalization, which are described by the patient's rejection, but heart disease involved in chest tightness, chest pain, and myocardial ischemia involved in heart disease The complexity of the inspection items and its limitations, the sudden results of the prognosis of the disease, the risks of critical seriousness, etc., have not fulfilled the obligation to fully inform, causing the affected party to fail to recognize and achieve attention. degree. The diagnosis and treatment behavior did not meet the "Regulations on the Management of Medical Division of Medical Institutions" of the Ministry of Health and had faults.

According to the above analysis, the appraiser believes that there is a fault in the patient's diagnosis and treatment, and there is a certain causal relationship between the fault of the medical party and the result of the sudden death of the patient. For the court, the degree of civil fault and the degree of civil compensation are determined according to the objective situation and the responsibility of the inspection of the non -row inspection.

The medical prescription did not recognize the appraisal opinion. The applied appraiser appeared in court and the appraiser appeared in court to testify:

1. Due to chest pain, based on the condition, patients are diagnosed with coronary heart disease and prescribed drugs that treat coronary heart disease.

2. My appraisal center makes a comprehensive judgment after fully considered the medical behavior and the consequences of the damage of this case. It is an inference in the science.

3. Because there is no autopsy on the patient, and the autopsy is the gold standard for the judgment of the cause of death. Therefore, my appraisal center mentioned in the appraisal opinion that the factor must be considered in the causal relationship;

4. The doctor's diagnosis and treatment measures meet the requirements of the guideline. I also noted that the patient's suggestion for refusing to check and hospitalization. The medical party has judged the danger. It should be fully inform and let the patient signed a letter of refusal to treat, and handed the doctor's order to the patient to attract the attention of the patient;

5. Patients did not follow the doctor's instruction to rest in bed on the day of sudden death, but rushed up early for a long distance. The behavior had an impact on the heart.

In summary, we have a certain causal relationship between the result of the medical party's sudden death of the patient, and it is recommended to be a minor responsibility.

The court finally recognized the appraisal center's appraisal opinion, and judged that the medical party bornered compensation in accordance with 10%, about 146,000 yuan, a mental loss of 20,000 yuan, and the appraisal fee of 1,8500 yuan and the appraiser's court cost of 2,000 yuan.

What are the problems with emergency electronic medical records?

After seeing many hospitals in Beijing, the three -in, second -level, and community hospitals have different levels, and the quality of emergency medical records is uneven.

The hospital in this case is a private hospital. Although it is a secondary hospital, the scale is not large. The emergency electronic medical records can save the complete medical records, electrocardiogram, CT images and reports on the system, and the doctor not only wrote a case within the specified time, but also wrote the content of the content on it. It is not easy.

It is precisely because of the comprehensive electronic medical record system and good medical record management regulations, and doctors have a good habit of completing the medical records, so that this hospital can come up with "evidence" at a critical moment, proves the patient diagnosis and treatment process, and the doctor's implementation notification The content and the patient's refusal to stay in the hospital, and the ECG test can be stored in the electronic medical record system, which is also very good.

However, from the perspective of the identification results, the appraisal experts have put forward many opinions on the medical records, medical records, and consent of the medical records of the medical prescription:

1. The patient refused the doctor's suggestion but automatically left the hospital, without the signature of the patient.

2. No files for patients, no certificates for diagnosis, and did not give the medical records to the patient, and failed to attract the attention of their families.

3. Insufficient informing the condition, insufficient communication, and not fully explaining the danger of the disease.

4. ECG reports are not standardized and lacks basic information of patients.

Is the appraisal expert too harsh? Is it wrong to quote the regulatory and management measures for medical records? Although there is no principle error, I always feel that it is not grounded, and the fault is found.

How can emergency medical records write all kinds of risks, explanation and communication content on medical records? The patient automatically leaves the hospital and requires them to sign. Those who have not done emergency department always feel like standing and not back pain.

How to avoid the risk of emergency medical records?

The management of emergency medical records is actually difficult. Complete electronic management is prone to many problems, such as the various informed consent forms signed by the affected party, the ECG of ECG, the report of the bedside testing items, and ECG monitoring printed wave -shaped Figures, etc. are difficult to directly convert into electronic medical records.

Therefore, even if the electronic medical record system is done well, many three hospitals have a good medical record in emergency response medical records, and they also need to write electronic medical records. When the patient leaves, after signing the two medical records (printed table medical records), one of them will be left; the first recipe for preservation of the emergency department will be placed together with other retained medical records, binding and preservation, not completely Relying on electronic medical records. The advantage of this is that all patients with emergency treatment can build files, and both doctors and patients with medical records can be preserved and are convenient for patients to sign.

The bad place is: the workload of emergency doctors is greatly increased. Each patient is equivalent to writing the medical records twice, and it is time -consuming and laborious for the preservation of emergency medical records.

Besides the second aspect, fully inform and communicate in -depth.

The pulse friends who pay attention to the column of "Medical Eyes" will find that many case appraisal centers will notify the patient's fault on reasons for the patient's understanding of the patient. The proportion of responsibilities based on this fault is basically mild responsibility, that is, the minimum responsibility that should be assumed.

The judgment of the case has been seen too much, and people feel that they will never be sufficient. As long as the mistakes are found, there must be a fault. It is wrong to not sign. The content of the notification is unreasonable. It is not in place in the condition of the condition that is not in place. There is no alternative to the fault. It is also a fault that there is an alternative.

If the content of all aspects is well written, the patient has also signed, and the patient still refuses to treat the plan. In the appraisal opinion, it is generally prescribed that the content of the informing may be sufficient, but the communication is not in place, which will cause the patient to not clearly understand and cause misjudgment of the condition.

Although in clinical practice, the medical prescription may indeed communicate with the affected prescriptions. Many knowledge consent is to go through the field, and even "only signature and not inform", but there are practical difficulties in clinical practice.

Medicine itself is a discipline that is difficult to understand. Although some doctors say, "I tell you what you understand?" It feels a bit stiff, but this is actually the truth. The judgment that doctors have many years of learning+N years of experience can only make patients understand for several minutes, which is also quite difficult.

Especially in the case of emergency treatment, there are not much time for each patient to get. In a short period of time, we must inform what kind of level to be enough, and don't be too demanding. Therefore, although the questions are always mentioned in the article, doctors should not be too tangled to inform the full question, just do it as much as possible. Because it is not enough, the reason is that if it is fully notified and communicated, the patient should be able to choose the right solution.

The loss of young life is always sad, but the reasons behind the analysis are even more heartbroken. A young man could go to the hospital late at night. He really felt that the symptoms were serious, but he was unwilling to accept the doctor's advice. Why?

The more patients pay attention to him, the more bitterly persuading him, the more he feels that you have another picture. Is the doctor wrong? Is the patient sick? Or the society has changed? People are chaotic?

No answer.

Adviser

Lawyer Xiang Heiman, Beijing Rightsman Law Firm (formerly Beijing Renchuang Law Firm), has long been engaged in medical law research and practice for a long time, and has rich experience in medical law.

The case in this issue comes from the Beijing Court Judgment Information Network

Responsible editor | Su Mu

Cover Map Source | Medicine Pulse Tong