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最近,天津市某区发生一起患者在村卫生室输液过敏死亡的医疗纠纷事件,患者家属起诉后,医疗机构申请医疗事故技术鉴定,但是医学会以没有门诊病历等原因中止医疗事故鉴定并向法院回函。当事方的村卫生室多次向区卫生局、天津市卫生计生委反映乡村医生没有书写门诊病历的资格,并且实践中都是门诊登记表作为门诊记录。通过调查河南、山东、安徽等地村医书写病历的情况,均反映在诊疗过程中确实不写病历,只有门诊工作日志和处方,这就导致村医一旦出现上述案例情况常处于法律被动地位。
Recently, a medical dispute occurred in an area of Tianjin where an infusion allergy died of a patient in a village clinic. After a family member filed a lawsuit, the medical institution applied for technical appraisal of the medical accident. However, the medical institution suspended the identification of the medical accident without the outpatient medical record, Reply The village clinics of the parties repeatedly reported to the District Health Bureau and Tianjin Municipal Health and Family Planning Commission that rural doctors did not qualify for the outpatient medical records, and in practice, they were all outpatient registration forms as outpatient records. By investigating medical records written by village doctors in Henan, Shandong and Anhui, it is reflected that medical records are not written in the course of diagnosis and treatment, and there are only outpatient work diaries and prescriptions. This often results in the passive status of the village doctors in the event of such cases.