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宁波一医院整治狂草病历 7名医生字迹潦草被罚款

2015-04-09 09:37:34   国际在线

有患者认为,病历上字迹潦草,是医生故意为之,患者看不清楚药名,就不能到医院外的药店买药。

医生们大呼冤枉。

一位医生说,早些年,患者看完病,确实需要拿着病历到医院配药窗口按照上面说明配药,但现在大部分正规医院都已使用了电子处方和无纸化办公,诊疗、开药、取药等步骤都是在电脑上完成的。患者可以在医院相关设备查询,还能打印出来,都是一目了然。

“手写处方仅是一种辅助手段,主要是为患者以后就诊提示病史,所以,故意潦草的猜测是不成立的。”这位医生说。

一位女医生提出,不太理解为何病历字迹要工整。她说,病历不是给患者看的,只要其他医务人员能看懂就行,“即使病人能看清每个字,有多少人懂其中的意思?病历最大的作用是,复查或再次就诊时作为参考、提示,另外就是发生医疗纠纷时作为证明。”

这位女医生说,有人认为医生字迹潦草是对患者没有责任心。其实对患者来说,医生最重要的工作是分析确定病情,并制定合理的治疗方案,“人的精力是有限的,患者那么多,如果我们把很大的注意力放在病历上,才是对患者病情的不负责。”

患者徐先生:

病历上药名看不清

跑了4家药店没买成药

上面这位女医生说,病历不是写给病人看的,只要其他医务人员能看懂就行,好像也有道理。不过,家住江北区的徐先生不同意这个观点。

徐先生有个9岁的女儿,前段时间女儿肚子疼。去医院后,医生开了药,门诊和药品窗口是联网的。从门诊出来,他就直接去取药了。开的药吃了三天,女儿症状减轻,但没痊愈。最后一天上班时,徐先生就揣着病历出门了,准备再买点药。

“因为病历上都是弯弯曲曲的小细线,我跑了4家药店,只有一家的工作人员猜出其中一种药的名字。实在没办法,下班后我赶回家,只好拿着药盒出来买药。”

徐先生得知医院整治狂草病历,连连说做得好。

快80岁的余姚人宋伯伯,也不会同意“只要其他医务人员能看懂”的说法。

前几天,宋伯伯眼病犯了,儿子带他到宁波一家医院。检查后,医生确认没有大问题。诊断快结束时,儿子出去接电话。医生嘱咐老人吃饭要营养均衡,还特意推荐了橘子、葡萄、香蕉等几种水果,都写在病历上。

回到家,宋伯伯只记得要多吃水果,但哪几种却想不起来了。儿子翻开病历,最后一行确实有几个字,似乎是水果名,但却认不出来。

宋伯伯的儿子只好赶回医院再去问医生。

追问:

医生字迹,同行是否能辨认

靠专业知识,大部分能猜出来

也有不少人好奇,病人看不懂的狂草病历,其他医生就能看懂?对此,钱江晚报记者问了不少医生。

一位医生说,他并不能认出所有病历的文字,有些过于潦草的,除非是很了解对方的书写习惯,否则也不认识。

“但大多数患者们很难看懂的病例,医生们确实更容易认得出来,这主要是因为病历都有一定的格式,根据格式,只要能看懂一两个字,根据专业知识,自然就能理解了。”这位医生说。

而且,病历上出现的一般都是专业术语或者药物的名字。这位医生举例子,比如扁桃体脓肿,只要看清一个“扁”或者“脓肿”中的任何一个字,甚至只看出这个词的轮廓,就知道了。还有一些药物,比如青霉素,看到“青”,在看到后面的剂量和药物单位,自然就明白了。

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