Introduction: Medical examination is a subject of medical diagnosis by using modern physical and chemical methods and means. This paper mainly studies how to provide evidence for clinical diagnosis and treatment through laboratory technology and medical instruments and equipment. Let me share my graduation thesis on medical examination, welcome to refer to it!

With the development of social economy, the progress of science and technology, and the improvement of people's cultural living standards, people's understanding and requirements for medical services are getting higher and higher, and their legal awareness is also increasing. Therefore, medical disputes occur from time to time. As far as the nature of laboratory work is concerned, it is a department that is easy to cause medical disputes.

Article 10 of Chapter II of the Regulations on Handling Medical Accidents: Patients have the right to copy or duplicate their medical records, temperature sheets, doctor's orders, laboratory tests, etc. Therefore, the quality of inspection report is the life of the laboratory. Examiners analyze and examine the various items of patients' specimens, and the accuracy and reliability of the results directly affect the diagnosis and treatment of patients by clinicians.

With the implementation of the Regulations on Handling Medical Accidents and the introduction of the inversion of burden of proof, clinicians and patients put forward higher requirements for the quality of inspection. How to prevent and deal with medical disputes in hospital laboratories is summarized as follows:

1. Quality service and "key" prevention.

The Standard of Hospital Civilized Language is a manual to strengthen medical staff's language cultivation, use civilized language, have a kind attitude, eliminate service taboos that affect the relationship between doctors and patients, and achieve "three good", that is, professional quality, professional ethics and good service attitude. Focus on preventing the following patients with dispute tendency, including patients with high technical requirements, special psychology and high examination costs.

Medical staff with dispute tendency include those with poor comprehensive quality, weak sense of responsibility and poor service attitude. Controversial periods include periods when there are few people and problems are handled independently, such as shift change, duty time, holiday time, etc. Common inspection items with controversial tendency. The focus of clinical laboratory is to test quality problems, such as the accuracy and reliability of results.

Timeliness, rationality of project cost, etc. The clinical laboratory must have evidence to prove that all the operations are standardized, the results are reported in time and the fees are reasonable.

2. Give priority to publicity and education, improve the legal awareness of inspectors and implement relevant laws and regulations.

According to the definition of medical malpractice in the Regulations on Handling Medical Accidents, medical institutions and medical personnel engage in medical activities in accordance with relevant laws, regulations, rules and technical specifications under the existing technical conditions, even if personal injury is inevitable, it does not constitute a medical accident. Therefore, inspectors must seriously study the "Regulations" and related laws and regulations.

For example, the Medical Practitioner Law, the Drug Administration Law, the Maternal and Infant Health Care Law, the Blood Donation Law, the Infectious Disease Prevention Law, the Occupational Disease Prevention Law, the Regulations on the Administration of Medical Institutions, the Regulations on the Administration of Blood Products, the National Clinical Laboratory Operating Procedures and some departmental and local norms. The implementation of "Regulations on Handling Medical Accidents" is not only the pressure on the work of hospital laboratory, but also the opportunity and motivation to promote standardization construction.

How to improve the inspection quality, keep close relationship with clinic, prevent the occurrence of medical accidents, and strengthen the consciousness of self-improvement, self-discipline and self-protection in the clinical laboratory is an important part of the future work of the clinical laboratory. The staff of the clinical laboratory must seriously study and be familiar with the relevant laws, regulations and provisions including the Regulations on Handling Medical Accidents.

3. Establish complete rules and regulations and operational norms.

Laboratory managers should carefully study and formulate strict rules and regulations according to the actual situation of the laboratory, so that there are rules to follow. At the same time, according to all kinds of experimental projects carried out in the laboratory, combined with the latest version of "Clinical Inspection Operating Procedures" and the latest inspection technology, the standard operating procedures suitable for our laboratory are formulated and the operating manual is written. The laboratory work is operated according to the standardized process, and the standardized operation by medical technicians is to prevent and reduce the inspection.

Reviewing medical disputes is a very important part. Standardized operating procedures are the basis of clinical laboratory work. One of the basic conditions of medical accidents mentioned in the Regulations on Handling Medical Accidents is that medical personnel violate the operating rules in medical activities, and standardized operation is the basis to ensure accurate inspection results.

Therefore, we should not only establish strict SOP (operating procedures) documents (including the requirements for specimen collection, transportation and preservation). Experimental methods, principles, steps, reagents and instruments, experimental working conditions, standards, interference, analyte reference values, quality control measures, etc. ), should also be strictly enforced. The strict implementation of the whole quality management system and operating procedures is an important evidence.

4. Do a good job in indoor quality control and inter-room quality evaluation.

Indoor quality control is the basis of improving inspection quality. Every time a specimen is determined, the quality of the determination results should be monitored with a known fixed value. Only when the obtained quality control results are within the specified range, the determined clinical specimen results are reliable. Otherwise, the instrument must be calibrated before it is used to detect clinical specimens.

For the inspection items without fixed quality control, attention should be paid to the response curve of the inspection and whether the precision of the results is good. The evaluation of porosity is a measure of the gap between our laboratory and other laboratories, and it is also a comprehensive evaluation index to test the accuracy of laboratory results. Inspectors should take it seriously and strive for good results.

We must take seriously the quality control of each room and room, and make records. When any project is out of control, it is necessary to make out-of-control analysis, out-of-control corrective measures and records. The excellent results of indoor quality control and interstitial evaluation are important evidence reference in case of dispute.

5. Strict specimen collection, inspection and preservation.

Qualified samples are the basis to ensure accurate test results. The collection of clinical specimens is usually carried out by nurses or clinicians, and the laboratory has paid little attention to it before, only focusing on testing.

However, due to incorrect collection methods, clinical specimens sometimes get wrong test results. In order to avoid this situation, the clinical laboratory should actively and regularly guide clinical workers, and if possible, provide a knowledge manual about specimen collection and preservation for clinical retrieval.

Through these efforts, we strive to provide good samples for clinical examination, avoid repeated collection of samples due to unqualified sample quality, and prevent medical disputes. In order to avoid the error of test results, the test specimens should be kept for at least 3 days.

Especially for qualitative samples, such as hepatitis, AIDS and other pathogen indicators, samples with positive results should be kept for at least 7- 10 days, so that patients can take out samples again for determination when they have doubts about the test results.

6. Attention should be paid to the original records of inspection results.

The results of various testing items are legally binding. There are high risks and unpredictability in medical work, which makes original records play an important role in the process of handling medical disputes. If the medical staff causes medical disputes because of changing the results, if the inspectors do not make original records, there will be problems such as unclear responsibilities and troubles.

Therefore, the original records of the results of each project should be carefully recorded, such as instrument model, reagent batch number, validity period, yin-yang comparison, specimen receipt, etc. , is also a part of the inspection work, is the direct evidence to reflect the inspection quality management. Therefore, it is imperative to establish and improve the original record system to make it standardized and scientific.

7. Strengthen self-protection awareness

There are many factors that affect the test results, both objective and subjective, and some people make mistakes in specimen collection, such as the name Zhang Guan Dai Li; Specimens were collected at the wrong time; Or the storage time after collection is too long; Or the wrong collection tube is used, which leads to inaccurate test results and medical disputes. Therefore, it must be indicated in the report that the result is only for the tested specimen.

Responsible. When receiving specimens, unqualified specimens should be returned. When the test results are inconsistent, it is necessary to communicate with the clinic and suggest re-examination. Because the specimens have been placed for a long time, some chemical components have changed greatly, and the specimens that cannot be detected in time should be properly preserved as required. The inspection report should be written clearly, and the result description should be scientific and rigorous. It is best to hand-write the signature of the inspector on the report, and then issue the report after verification.

8. Pay attention to the review of suspicious reports.

In clinical examination, if the results of numerical tests such as blood routine and biochemical tests are particularly abnormal, you should contact the clinician first. If the results are inconsistent with the clinical diagnosis, the specimen must be re-tested. If there is no obvious difference between the second measurement result and the previous measurement result, the two measurement results will be fed back to the clinician together, and the recheck result will be indicated on the recheck report form to attract the attention of the clinician, and blood will be drawn again for recheck if necessary.

If the result is quite different from the previous one, it means that there is something wrong with my work or the instrument, and I need to solve it further before I can issue the inspection report.

9. Strengthen the sense of responsibility and communication with clinical departments.

Inspection work is an important part of hospital medical work. Improving inspection quality is the focus of laboratory work, and it is the duty of our inspectors to provide fast and accurate inspection results for clinical departments. Therefore, in daily work, we must take every specimen seriously with a high sense of responsibility and put quality first.

At work, clinicians often accuse our laboratory of inadequate services and inaccurate results. At this time, on the one hand, we should check whether our work is done well, on the other hand, inspectors should constantly strengthen communication with clinicians, sort out the purpose, purpose, significance and results of various inspections, and send them to clinicians; When the test results are abnormal, contact the clinician in time to verify whether the results are consistent with the patient's condition; Communicate with clinicians regularly, exchange opinions, summarize clinical feedback information in time and seriously, and continuously improve the quality of inspection. If our work is not done well, we should listen to timely improvement with an open mind. The results of positive indications should be kept confidential for patients, and the privacy of patients should not be revealed.

10. Improve the writing of inspection report.

The inspection report should follow the requirements of the Basic Specification for Medical Record Writing (Trial) in form, so as to be complete, accurate and timely. The inspection report shall not be altered or forged. In the process of reviewing the report, the places that need to be revised should not be smeared, the wrong contents should be deleted with horizontal lines, the handwriting should be clear and easy to read, and then the correct contents should be written next to it. In terms of content, the description of the inspection report should be scientific, objective and rigorous, and it is best to indicate "only responsible for the detected specimens". All test results should be carefully registered one by one, so as to supplement them in time when they are reported missing.

Focus on preventing the quality of inspection reports and avoiding medical disputes in inspection reports. Focus on "three checks and three pairs", that is, check the patient's name, bed number, specimen type and test items. Carefully check the inspection report, register in detail, and implement the signature responsibility system. Every day, no matter ordinary patients or emergency patients, in order to prevent the loss of application forms, specimens and test results, we must record the time of each link and record the measures transmitted with the specimens.

Time, year, month, day, hour, minute, subject, name, number, bed number, specimen type, inspection items, etc. It shall be recorded and signed by the sender and the receiver. If the test results are high or low, or the results are difficult to explain, it is not easy to issue a report. Before issuing the report, you should contact the clinical department, explain the situation and carefully review it, and record the specimen results and signers in detail in the register.

Name and handling. Emergency specimens should be handled in time and notified by telephone in time so that a report can be issued within the year. Keep samples after testing for review and verification.

1 1. Strengthen communication and make common progress.

In short, in order to prevent medical disputes in inspection correctly, inspectors need to cultivate good professional ethics, improve service attitude, strictly abide by relevant laws, regulations, rules and technical specifications, constantly enhance quality awareness, strengthen communication with clinicians, enhance self-protection awareness in work, and work hard to prevent medical disputes in inspection effectively.

;