Hospital doctor-patient communication system

With the transformation of medical models and the continuous improvement of China's health legal system construction, the improvement of people's living standards, cultural quality and awareness of rights protection, the medical information that patients want to obtain is increasing. Therefore, strengthening communication between doctors and patients can not only improve the patient's understanding of the whole process of disease diagnosis and treatment and its risk, but also reduce the contradictions and disputes between doctors and patients due to information asymmetry. At the same time, it can enhance the medical staff's Responsibility awareness and legal awareness improve the quality of medical services, enabling patients and their close relatives to learn more health and hygiene knowledge, breaking superstition, enhancing mutual trust between doctors and patients, and scientifically fighting diseases. In order to adapt to the new situation, protect the legitimate rights and interests of patients, prevent the occurrence of medical disputes, maintain a good medical order and the vital interests of the majority of medical personnel, ensure medical safety, resolve the contradiction between doctors and patients, and steadily improve the quality of medical care at a deeper level. system.

First, the execution object:

All employees of our hospital should abide by this system in the course of providing various services to patients.

Second, the timing, content and requirements of doctors and patients in various positions

In addition to the initiative, enthusiasm, courtesy, sincerity, gentle tone, and satisfactory answers to questions raised by patients and relatives, all staff in the hospital need to communicate with patients and relatives in a satisfactory and effective manner:

1. Guide doctor: Take the initiative to understand the current needs of patients and give satisfactory answers.

2. Registration room: Know the patient's name, gender, age, address, postal code, contact number, occupation, work unit, etc. Pediatric patients also need to know their guardian status.

3. Outpatient first-time physician: The first-time clinician of the outpatient clinic is in accordance with the provisions of the “Responsible for the First Physician”. At the time of admission, the patient should make a preliminary diagnosis based on the patient's past medical history, current medical history, physical examination, and auxiliary examination, and arrange for further diagnosis and treatment, solicit patient opinions, and inform the living, diet, activities, and treatment. Precautions and other content until the patient is satisfied to leave. Those who need further examination or treatment should outline their necessity, compliance, and cost, and direct or escort the patient to the next procedure.

4. Inpatient department: When the patient goes through the hospitalization procedure, pays the advance payment, settles, inquires, etc., the staff of the hospitalization department should introduce the price execution standard of the hospital to the patient, and explain the reason and accounting of the expenses. The process eliminates the misunderstanding of the patient. In case of dispute, the staff of the inpatient office shall take the initiative to contact the staff of the source of the expenses and provide communication and explanation from the source of the expenses. If the admission to the hospital is incorrect, you should take the initiative to apologize.

5. Communication during hospitalization in the ward

Communication at admission: No matter who found the patient's new arrival, the ward staff should take the initiative and enthusiasm to call and contact the nurse on duty to receive the reception. After receiving the new patient, the on-duty nurse informs the patient of the hospitalization instructions, precautions, life guides, etc., and helps the patient to familiarize with meals, water, and toilets. After confirming the treating physician and the responsible nurse, the patient should be informed of the name of the treating physician and the responsible nurse, and the name should be indicated on the bedside card.

First Physician in the ward: The first Physician in the ward is admitted according to the "First Physician Responsibility System". The on-duty doctor should actively greet the patient before the end of the new patient care program, inform the inpatient treatment program, eliminate the anxiety, nervousness, and get the patient's cooperation. Once the nursing program is over, the on-duty doctor will start the treatment program. Introduce your name to the patient before the consultation, and be enthusiastic and sincere. Immediately after the completion of the first course record, the patient and the family should be initially communicated with the initial diagnosis, possible causes of the cause, principles of diagnosis and treatment, contents of further examination, diet, rest, and precautions.

Patients admitted to the emergency department should start the diagnosis and rescue activities at the same time as the nurses are in the hospital, and inform the relevant contents and write the critical notice. A critically ill notification should be signed by a close relative or agent and agree to the proposed treatment plan.

Due to risks, expenses, etc., the patient should formulate a secondary selection plan if he or she does not agree with the best diagnosis and treatment plan, and choose the secondary selection plan for the patient to agree to choose the best option.

Communication within three days of admission: The medical staff must communicate exactly within three days of admission. The medical staff should inform the patient about the diagnosis and treatment of the disease, the main treatment measures, the expected results and the next treatment plan, the need for the patient to cooperate, and the patient's opinion and experience of the diagnosis and treatment. relationship.

Communication during hospitalization: including changes in the condition, invasive examination and before and after risk treatment, change of treatment plan, use of valuable drugs, arrears, timely communication of critical illness with disease, preoperative, intraoperative changes, preoperative procedures Communication with drugs, projects, etc. before transfusion and beyond medical insurance. The above situations should be communicated in a timely manner to eliminate the adverse effects of the patient's bad mood on the diagnosis and treatment.

At the time of discharge: in addition to the normal discharge certificate and discharge record, the medical staff should clearly explain to the patient the patient's medical treatment, discharge of medical advice and discharge notice, follow-up and follow-up time. A diagnosis certificate and a copy of the medical record should be issued to the patient when needed. Diagnostic certificate stamping and copying medical records should be handled by the treating physician.

6. Communication between medical and technical departments and other assisted medical departments: including radiology, ultrasound, endoscopy, electrophysiology, functional examination, laboratory, pathology, bacteria room, operating room, special treatment room , rehabilitation room, acupuncture and physiotherapy, other outpatient specialties. The above-mentioned departments should actively greet patients to enter the diagnosis and treatment program, explain the precautions, answer questions from the patients within the scope of business of the department, and introduce the purpose of diagnosis and treatment. The communication should be consistent with the applicant's calibre to avoid ambiguity and adverse consequences. It is absolutely forbidden to answer the consultations from the above-mentioned departments beyond the scope of professional practice. Communication should be conducted to understand the patient's medical history information when necessary.

7. Pharmacy: The pharmacy pharmacist should take the initiative to do a good job in window reception when preparing prescriptions. When there is a problem with the prescription, you should say "I'm sorry, there is a place I can't see clearly. I will ask the doctor, please take a moment." After obtaining the consent of the patient, you should take the initiative to seek the relevant doctor to make changes. correct. When issuing the medicine, you should explain the method of use and precautions for each medicine until the patient is satisfied.

8. Toll collection office: Refer to the hospitalization office for execution.

Third, communication notes:

1, communication should strive to use the popular expression

Language, attention can neither cause ambiguity nor cause unscientific fantasies of patients.

2, communication should pay attention to the level of content. According to the severity of the disease, the complexity and the poor prognosis, communication is carried out by different levels of medical staff. At the same time, according to the cultural level and requirements of patients and their close relatives, different ways of communication. If there have been disputes, it is necessary to focus on communication.

3. Collective communication can be carried out on common diseases, common diseases, and seasonal diseases.

4. For difficult and critically ill patients, the patient's department or group will formally communicate with the family members; for patients with high risk of treatment, unsatisfactory results and poor prognosis, the director of the department should preside over the consultation within the department. Patient communication.

5. For patients who may have problems in medical activities, they should be targeted as preventive communication. Preventive communication should be recorded in the course of the disease and signed by the patient if necessary.

6. Those who have difficulty communicating or have difficulty communicating with the patient should communicate with other medical personnel.

7. When the diagnosis is unknown or the condition deteriorates, the medical staff in the department should discuss it first, and then coordinate and then communicate again to avoid the patient's distrust or doubt.

8. When communicating, you can use the physical objects, maps, specimens, models and other comparative explanations to increase the patient's perceptual knowledge and facilitate the patient's understanding and support for the diagnosis and treatment process.

Fourth, communication skills:

Communicating with the patient should reflect respect for the other party, patiently listen to the other person's complaints, sympathize with the patient's condition or encounter, and be willing to give a patient a loving attitude and proceed in good faith. At the same time, you should master the following skills:

1. A skill: listen to the patient or family member and say a few words. Try to let the patient and family vent and confide, and explain the patient's condition as accurately as possible.

2, two mastery: master the condition, examination results and treatment; master the psychological pressure caused by medical expenses to the patient.

3, three attention: pay attention to the educational level, emotional state and communication experience of the communication object; pay attention to the communication subject's awareness of the condition and expectations of communication; pay attention to their emotional reactions, learn to control themselves.

4, four avoidance: avoid using the tone, tone, and statement that stimulate the other party's emotions; avoid suppressing the other party's emotions, deliberately change the other's point of view; avoid excessive use of the professional vocabulary that the other party is not easy to understand; avoid forcing the other party to immediately accept the doctor's opinion and facts .

V. Communication Record Each communication of the medical staff should be detailed in the medical record or nursing record of the medical record. The recorded contents include: time, place, medical staff participating, and the names of the patients, relatives, actual contents, and communication results. Important communication records should be signed and signed by the patient.

Sixth, evaluation:

1. The communication between doctors and patients is the routine content of the medical record, and is included in the hospital quality assessment system and independently used as the quality control point.

2. If there is no complaint or dispute caused by improper communication or communication between the doctors and patients as required, bear all losses.

7. This system is interpreted by the Office of the Hospital Total Quality Management Committee.

8. These regulations shall be implemented from September 1 of the following year.