Chapter 20 Revised Medical Records
Dean Xiao looked at Gu Fan's previous satisfaction with the patient's examination and diagnosis, glanced at the patient lying on the bed, and asked with a refined expression, "Gu Fan, what do you think needs to be paid attention to in the follow-up treatment?"
Gu Fan took off his gloves and explained to Gu Yue about the quasi-font size.
Hearing Dean Xiao's words and asking, Gu Fan was stunned, is it appropriate for this Dean Xiao to treat me in front of so many people?
"The patient has a serious infection, so he pays attention to his body temperature, and the condition of the wound on his body is recorded and recorded. Gu Fan looked at the medical environment in the room, as well as the quilt cover and sheets on the bed. I have a general understanding of the nursing environment of the hospital, and I have a preliminary understanding of the patient's family habits through the treatment just now. After thinking about it, he finally said, "Bacterial culture, determine the cause of infection, and divide the responsible party." ”
When Gu Fan said this, the doctors in the entire ward were frightened.
Postoperative infection is present in the risk of surgery, and there is a signature on it when the patient is pushed into the operating room, but what does he mean by saying this at this time? The surrounding doctors looked at Gu Fan in surprise, and they were even more dissatisfied with Gu Fan in their hearts.
Dean Xiao frowned, he heard the meaning of Gu Fan's words, the cause of the patient's infection may be an operational problem in the hospital, but can this kind of doubt be said in front of the patient?
Fortunately, the woman didn't hear the meaning of the words, and thought that Gu Fan wanted to investigate the cause of the infection and help the hospital clear up the relationship. The woman originally had a grudge against this hospital, and when she heard Gu Fan say that she was responsible, she looked at Gu Fan angrily, "You mean that my child's wound infection is our cause, and you want to clear the responsibility?"
Gu Fan shook his head, "No, on the contrary, I'm defending your rights and interests. ”
Gu Fan studied medicine with his grandfather since he was a child, and went to study in country M at the age of 16. There patients and their families are equal to the hospital and have no affiliation. It was precisely because of this that Gu Fan directly said the words in his heart.
"Your child's infection is considered medical malpractice, and the hospital will cover all the costs of your child's subsequent treatment. Gu Fanyu was not shocked, and he spoke again.
Gu Yue heard Gu Fan's words and pulled her brother's sleeve vigorously, she lives in China and makes friends extensively, her brother will work in this hospital in the future, how can she offend the hospital at this time. The more I thought about it, the more anxious I became.
Gu Fan patted the back of his sister's hand and looked at Dean Xiao, who was standing there frowning and his face gloomy. "The doctors at the hospital did not do a good job of post-operative treatment, and I personally suspect that there was a false description of the patient's condition in the medical records. ”
"What's wrong with a patient's medical records?" the doctors discussed with each other, and the attending doctor's face turned from pale to dead gray.
"How is this possible, there are strict requirements for diagnosis certificates and medical records, and they cannot be faked!" a chief doctor stood up and stared at Gu Fan. "You have to have proof of what you say, or we will suspect that you are slandering. ”
Gu Fan's words sounded to other doctors, not only talking about the attending doctor, but also a naked denial of the people engaged in this hospital.
Gu Fan picked up the medical record on the table, "The patient's diagnosis certificate and medical records cannot be easily modified, and if there is any amendment, it needs to be signed by the chief physician or above." On the second page of the medical record, the patient's symptoms of infection were severely altered, and the reason for the alteration was not stated. ”
Dean Xiao was shocked when he heard Gu Fan's words, if it was really as Gu Fan said, the patient's family made trouble with the Ministry of Health, and when the time came to see the medical records, no matter how good the hospital was, in the end, because of the alteration, the responsibility would be completely planned to the hospital.
Dean Xiao took the medical record from Gu Fan's hand, turned the second page, and saw that the time recorded on it was the day when the patient's infection worsened a week ago. The third line was pulled with a black pen and written below again, again writing the patient's condition. Comparing the medical records before and after, this newly written description of the condition is completely inconsistent.
The more Dean Xiao looked at it, the more angry he became, and there was more than one place to make corrections, there were three places, all of which were modified when the patient's condition deteriorated. After reading the case in his hand, Dean Xiao slammed the medical record on the team leader of the attending doctor. "Take a good look, your good crewmate. ”
Dean Xiao turned around, looked at the woman, and bowed deeply, "It was our hospital's work mistakes that delayed and aggravated the patient's condition, and I apologize on behalf of the hospital for you and the patient." ”
The woman saw the old man in front of her, who was about the same age as her father, suddenly bowed and apologized to herself, and hurriedly stepped forward to support Dean Xiao, "You don't need to be like this, the First People's Hospital is the best hospital in the city, I believe it is just an example, I only hope that my child can get effective treatment now." The woman glanced at her son, who was lying on the hospital bed.
Dean Xiao nodded at the woman, "This is a mistake on the part of our hospital, thank you for your understanding." All expenses of your child in the hospital will be borne by our hospital, as long as you raise the follow-up compensation issue, as long as it is reasonable, we are willing to pay. ”
The team leader of the attending doctor picked up the medical record from the ground and opened it, saw the traces of alteration, and glared at his team members fiercely. The surrounding doctors all gathered around him, took the medical records from his hand and looked at them, and couldn't help but shake their heads when they saw the marks on them, and they had lost the need to continue reading.
Gu Yue didn't understand why the case couldn't be altered, so she asked, "Why can't the medical record be modified?"
Gu Fan looked at his sister, "The medical record is a dynamic record of the patient's hospitalization, which records all the patient's medical conditions and medication during the hospitalization. Cases require objectivity, accuracy, truthfulness, and validity. The altered case destroys the objectivity of the medical record, which means that the modified medical record does not have any legal effect. No matter how accurate and true the amendment is, it will not be recognized by the courts and the Ministry of Health. ”
"Can't the medical records be modified at all?" Gu Yue looked at Gu Fan with a pair of beautiful eyes.
"To be exact, it can be modified, but this change needs to be signed by multiple hospital leaders, and the reason for the change needs to be stated in the new medical record, and the old cases also need to be kept as a basis. ”
The woman looked at Gu Fan standing in the crowd, and at the same time felt very grateful and understood that she had misunderstood him just now, "Young man, thank you, I misunderstood you just now." ”
Gu Fan shook his head, "I'm a doctor, and I want to be worthy of every patient, so you don't need to thank me." ”
Xiao Zhan glanced at Gu Fan gratefully, Gu Fan's words were to dispel the woman's concerns about the hospital and correct the name of the hospital. At the same time, it is also thanks to Gu Fan for discovering that the case was modified in time, if the patient takes this medical record to the court to sue the hospital, the hospital will suffer a greater loss, and this loss is not only money, but also reputation. Now the contradiction is still in the hospital, so the contradiction is much easier to solve, as long as the patient and the patient's family can be comforted, and at the same time the patient is treated, then the contradiction between the hospital and the patient has been properly resolved.
When the woman heard Gu Fan's words, she was very satisfied with this young man, and the careful and serious way he had treated her son's wounds just now had touched her heart.
"Are you the doctor in this hospital, and can I leave my child's illness to you?" said the woman, who thought for a moment.
Gu Fan shook his head, "Not yet!"
The woman sighed in her heart when she heard Gu Fan's words, and there was some disappointment, the responsible attitude of the young man in front of her, she believed that if she handed her son over to such a doctor, her son would be better treated. "That's a shame. ”
Dean Xiao hurriedly answered, "Gu Fan is already our hospital today, but the department he works for has not yet been determined. ”
The woman asked suspiciously, "The department of work has not been determined yet, isn't he from the orthopedic surgeon?"
Dean Xiao said with a smile, "Gu Fan has a lot of professional fields, and the hospital is considering which department to let him go to!"
The woman didn't use medicine very much, and she didn't understand what Dean Xiao said, saying that she knew.
And the doctors in the hospital are not clear when they hear the words of the director, some doctors have multiple specialties, but they don't understand it very well when there are more professional fields. Could it be that this young man has other skills besides orthopedic surgery?
After comforting the patient's family, Dean Xiao looked at the other doctors with a straight face, "Everyone go to the duty room for a meeting." ”