家属质疑：为何属“一级护理”病人，死前4小时却没有护理记录院方回应：建议家属做医疗鉴定

Family question:Why is"Primary care"The patient,Dead four hours before but no nursing records the response:Suggest family do medical appraisal

　　刚满周岁的林小轩(化名)，在住院四天后，死了。

Just full one full year of life XiaoXuan Lin(alias),After four days in hospital,died.

　　因为发烧怀疑是患了麻疹，她于9月6日到福州市传染病医院住院治疗。住院的前三天，她的病情还算稳定，直到9月10日凌晨，一场恶梦开始。

Because a fever doubt is had measles,She on sept. 6 to fuzhou infectious disease hospital treatment.The first three days in hospital,She was still calculate stability,Until September 10, morning,A nightmare start.

　　谁也不知道，从开始发烧到生命结束的短短6个多小时，小轩小小的身体，经受了怎样的痛苦。小轩的爸爸林有民称，在孩子死亡前的几个小时里，医护人员都没有到场了解孩子的病情。他也多次在孩子发烧后，寻求医生和护士的帮助，但他们并未及时出现。

Who also don't know,From the beginning to the end of the fever life short more than six hours,XiaoXuan small body,Through how pain.XiaoXuan father LinYouMin says,The child before death several hours,Medical personnel are not to know the child's illness.He also many times in children after a fever,Seek the help of the doctors and nurses,But they did not appear in time.

　　

【家属质疑】 [Family question]

　　一级护理的患儿持续高烧到40℃为何不见医护人员？

Primary care for children with high fever to 40 ℃ why no medical personnel?

　　据林有民介绍，因为持续发烧三天，9月6日，一岁的女儿小轩从宁德市医院转到福州市传染病医院治疗。当日下午，经医生诊断，以“发热，皮疹待查：麻疹？”将小轩收住院。

According to LinYouMin introduced,Because of persistent fever three days,On September 6,,One year old daughter XiaoXuan from ningde city hospital turned to fuzhou the infectious disease hospital treatment.That day afternoon,Classics doctor is diagnosed,to"fever,Rash in dispute:measles?"Will XiaoXuan accept in hospital.

　　入院后，小轩的病情还算稳定。9月9日晚上7时，小轩挂完点滴，安然入睡。但没想到，9月10日0时30分许，小轩又发烧了，38.7℃。林有民马上报告护士，护士给孩子吃了3毫升的布洛芬混悬液退烧。

After admission,XiaoXuan condition still calculate stability.On September 9, 7 in the evening,XiaoXuan hang out a bit,Enron sleep.But I didn't know,On September 10, 0 30 points make,XiaoXuan and have a fever,38.7 ℃.LinYouMin immediately report the nurse,The nurse to give children ate 3 ml of ibuprofen suspension fever.

　　到了凌晨5时40分许，林有民自己觉得不对劲，再给孩子测体温，发现孩子烧到了40.2℃。他觉得情况不妙，赶紧找值班医生，没找着，又去找值班护士。值班护士让他自己用冰块物理降温。他找来冰块用布包着敷在小轩腋下进行降温。过了几分钟，他量孩子腋下体温为38℃。他不放心，再隔了几分钟，他又量孩子体温，发现升为38.5℃。

5 in the morning when xu 40 points,LinYouMin feel wrong,Give children temperature,Discover the child burn to 40.2 ℃.He felt well,Find the doctor on duty immediately,I can't find them,And to find clerk.Clerk let himself with ice cube physical cooling.He sought to ice with cloth with apply is in XiaoXuan axilla cool down.After a few minutes,He measured the child axillary temperature is 38 ℃.He doesn't trust,Then after a few minutes,He measured the child body temperature,Found up to 38.5 ℃.

　　林有民再次去找了护士，护士建议他找医生。于是，他赶紧去医生办公室找人，医生建议他给孩子吃3毫升的布洛芬混悬液，此外再无任何处理方式。

LinYouMin again to find the nurse,The nurse suggested that he find a doctor.so,He hurried to the doctor's office for someone,The doctor advised him to give the child to eat 3 ml of ibuprofen suspension,In addition to without any treatment.

　　没想到，这次一喂完药，孩子立马就脸色发白，全身发软了。同病房的家长说，这情况不对。他赶紧抱着孩子直奔值班医生办公室。医生发现情况严重马上实施抢救。这时候孩子已经没有了呼吸，医生抢救了一个多小时未能奏效。10日上午7时，医生宣布小轩抢救无效死亡。死亡原因为：心跳呼吸骤停。

Didn't expect,This a finish feeding medicine,The child immediately turn white,Whole body has become feeble the.With ward's parents said,This situation not.He hurriedly hold children to watch the doctor's office.The doctor found serious implementation of the rescue immediately.At that time the children have no breath,The doctor rescue for over an hour fail to work.10 the 7 am,The doctor declared XiaoXuan rescue invalid death.Cause of death for:Cardiopulmonary arrest.

　　孩子的死亡，让林有民一家难以接受。小轩的家人质疑医院的管理以及对病人的诊疗存在问题，从而让他的孩子、一名需要一级护理的病人从当日凌晨2点到6点，持续发烧到40.2℃，却没有医护人员到场进行检查和处理，导致孩子死亡的悲剧发生。他说，按规定一级护理的病人，医护人员必须一个小时来巡查一次孩子的病情，如果医护人员尽到责任，及时发现孩子病情变化，及时采取措施，也许孩子就不会死亡。

The death of the child,Let LinYouMin a hard to accept.Question XiaoXuan family hospital management as well as to the patient's medical problems,So that his child/A need to primary care from the patients at 2 PM and 6 PM,Persistent fever to 40.2 ℃,But no medical personnel to inspect and processing,The tragedy of death in children.He said,In accordance with the provisions of the primary care patients,Medical staff must be an hour to patrol a children's illness,If medical personnel obligations,Timely discover the child condition changes,Take timely measures to,Maybe the child will not death.

　

　【院方回应】 [Response to the hospital]

　　入院当天已经下发病重通知 The admission notice issued seriously ill

　　患者高烧体温下降可4小时后再测 Patients with high fever hypothermia can be measured again after 4 hours

　　针对患者家属的质疑，福州市传染病医院给记者发来了《关于###医疗过程的情况说明》。

According to the families of the patients with question,Fuzhou infectious disease hospital to reporter the other day[About # # # medical process circumstance explains].

　　说明认为：患儿入院当日即下达病重通知，并由其父亲林有民亲自签字确认，病历中有原始记录。

Shows that:Children to the hospital that day to notice is seriously ill,And the father LinYouMin signed confirmation,Medical records are the original record.

　　为何一级护理却4个小时不见护士来检查？医院回应说，当班护士在9月10日00:00交接班时看过患儿后，严格按照一级护理的规范每一小时巡视病房一次，并将巡视情况记录于“病重、一级护理巡视卡”上；根据诊疗常规，患儿体温38.5℃以上即可服用退烧药。该患儿在凌晨00:30发热38.7℃时服用了一次布洛芬，凌晨近6：00发烧至40.2℃，不足6小时药物半衰期情况下，先采取物理降温即冰敷形式，且该患儿在住院期间反复发烧，最高体温曾达到40.2℃，经口服布洛芬及冰袋物理降温后体温能够下降；02:00时，患儿体温下降至37.5℃并入睡，根据护理常规，患者体温下降到37.5℃，可4小时后再测体温。06:00护士通知患儿父亲给患儿量体温，并未违反护理规范，对患儿的护理到位。

Why level of care but four hours to see the nurse to check?Hospital responded that,The nurse on duty on September 10, he prefer when seen after children,In strict accordance with the level of nursing standard every hour tour ward a,And will patrol record in"Seriously ill/Level 1 nursing rounds card"on;According to conventional diagnosis and treatment,Temperature 38.5 ℃ above children can take antipyretic.The child in the morning 38.7 ℃ 00:30 fever when taking a ibuprofen,Nearly six in the morning:00 a fever to 40.2 ℃,Less than 6 hours drug half-life cases,Take physical cooling namely ice forms,And the child in hospital in repeated fever,The highest temperature was 40.2 ℃,Oral ibuprofen and ice pack after physical cooling temperature can drop;At 02:00,Children body temperature dropped to 37.5 ℃ and go to sleep,According to conventional nursing,Patients body temperature drops to 37.5 ℃,But after four hours to temperature.Notice to surf the nurse children father children's temperature,Not in violation of nursing standard,To the patient's nursing in place.

　　医院认为：他们对该事件十分重视，于2012年9月10日下午即召开院内专家委员会会议，经过取证调查，认真讨论，一致认为，患儿在福州传染病医院治疗的近90个小时内诊断明确，在医疗、护理上无任何过失，死亡是其病情危重，迅速发展导致的结果。如家属有异议，建议其通过法律程序进行医疗鉴定。

Hospital think:In the event they attached great importance to,In 2012 September 10th afternoon held that nosocomial experts committee meetings,After forensics investigation,Discuss carefully,Agree that,In fuzhou children infectious disease hospital treatment of nearly 90 hours clear diagnosis,In the medical/On nursing without any fault,Death is its critical illness,The result of rapid development.Such as family members have objections,The Suggestions through legal procedures medical appraisal.

　　福州市传染病医院医务科林科长在接受采访时表示，“如果结果判定我们有错，我们愿意承担相应的赔偿。在医院没有过错的情况下，根据患者的经济情况，医院可以给予一定人道主义的援助。”

Fuzhou infectious disease hospital medical colin section chief said in an interview,"If the result decision we have wrong,We are willing to bear the corresponding compensation.In the hospital under the condition of no fault,According to patients' economic conditions,The hospital can give a certain humanitarian aid."

　

　【声音】 [voice]

　　家属手中保存了一叠厚厚的病历，根据家属提供的复印病历，一些业内人士提出了一些看法。家属也表达了自己的声音。

Family hands kept a pad of heavy medical records,According to family members to provide copy medical records,Some in the industry put forward some views.Family members also expressed his own voice.

　

　声音1 Voice 1

　　孩子病历中的“病重”是否被修改？如果下达“病重”为何没有特殊护理？

Children in the medical records"Seriously ill"Whether be modified?If issued"Seriously ill"Why no special care?

　　业内人士称，从家属提供的病历资料上来看，其中存在一些自相矛盾的细节。

The personage inside course of study says,From family members provide the medical records to see,Among them there are some details of the contradiction.

　　9月6日下午2点，入院病历上显示，孩子的体温为37.5℃，这个不算高，同时，双肺以及心脏检查也都显示无明显异常，精神、反应良好，发育正常……初步诊断的结果为：1.发热、皮疹待查：麻疹？2.先天性耳聋；3.精神、运动发育迟滞。

On September 6, 2 PM,The hospital medical records show,The child's temperature is 37.5 ℃,This is not high,At the same time,Double lung and heart inspection are also shows no obvious anomaly,spirit/Reaction good,Development normal...The result of preliminary diagnosis for:1. The fever/Rash in dispute:measles?2. Congenital deafness;3. Spirit/Movement retardation.

　　一般来说，医生对于入院体格检查最认真。“精神、反应良好，发育正常”与诊断结果“精神、运动发育迟滞”，这种矛盾的说法有点让人搞不懂。

Generally speaking,A doctor to the hospital physical examination for the most serious."spirit/Reaction good,Development normal"And diagnosis results"spirit/Movement retardation",This kind of contradiction that is a bit confusing.

　　同时，在医嘱单中，9月6日下午两点，医生下了“病重”的医嘱。这显然与上面入院病例体格检查的结果不符，体格检查中用到的词都是“未”、“无”，但是医嘱中却显示“病重”。病重的依据是什么？病人没有脱水外观，也没有昏迷、神志不清、高烧等症状。

At the same time,In the doctor's advice in the single,On September 6, at two o 'clock in the afternoon,The doctor"Seriously ill"says.This obviously and above cases to the hospital physical examination results discrepancy,Physical examination is used in word"not"/"no",But the doctor's advice but display"Seriously ill".What is the basis of seriously ill?The patient no dehydration appearance,Also does not have the coma/dottiness/Symptoms such as fever.

　　此外，病重通知下医嘱需要家属签字，病历中也未见家属签字的相关病重通知书。那么6日下“病重”医嘱有点不符合规定。

In addition,Seriously ill tell family members need to sign the doctor's advice,Medical records also did not see the relevant notice signed by family members became seriously ill.Then 6 ("Seriously ill"A doctor's advice is not in conformity with the provisions.

　　业内人士表示，根据上述资料来分析，存在两种情况，一种情况是孩子确实有问题，但医生不认真，忽视了，没有写在入院病历中。另一种情况是正如家长所说的，孩子确实没有问题，医嘱首页在事后做了修改。

The personage inside course of study says,According to the above information to analyze,There are two kinds of cases,A kind of circumstance is children do have problem,But doctors don't seriously,ignored,No written in the hospital medical records.Another kind of circumstance is as parents said,Kids really no problem,The doctor's advice in the home page after modification.

　　“医院在说谎。”针对医生当天已经下了病重通知的事情，孩子父亲林有民表示，孩子入院时体格检查的指标都很不错，他根本没有签过医院下发“病重”的通知，如果孩子真的病重，按照护理要求，级别就不是针对病情趋向稳定的一级护理，而应该是特殊护理了。

"Hospital lying."According to the doctor has been seriously ill notice things,Children LinYouMin father said,The child admission physical examination index are very good,He did not sign a issued by the hospital"Seriously ill"notice,If the children really seriously ill,According to care for,Level is not according to the illness tend to stable level of care,And should be the special care.

　

　声音2 Voice 2

　　

病重患者高烧6小时没有进一步采取措施不符合常理 Seriously ill patients with high fever six hours without further take measures do not conform to the common sense

　　业内人士还提出，如果按院方说法一入院就“病重”，且住了4天仍反复发烧，病情不稳定的病人，在发烧最高到40℃以上的6个小时中，病历资料中都只显示，简单服用退烧药，和物理降温，而没有进一步检查和采取措施，这有点不符合常理，特别是在凌晨2点到6点的时候护理病历中也没有任何记录。

The personage inside course of study also proposed,If according to the hospital saying is a admission"Seriously ill",And live for 4 days and still have a fever,Illness unstable patient,In a fever of 40 ℃ above the highest to six hours,Medical records are only show,Simple take antipyretic,And physical cooling,And no further examination and take measures,It's a bit does not comply with the common sense,Especially in 2 a.m. to 6 o 'clock when the nursing medical records also does not have any records.

　　按照卫生部的相关规定，由护士根据医嘱和病情对危重患者住院期间护理过程进行客观记录。凡特护、病危、病重、特殊治疗、需严密观察病情及大手术后三天内的患者应使用危重患者护理记录。内容包括患者姓名、科别、住院病历号(或病案号)、床位号、页码、记录日期和时间、出入液量、体温、脉搏、呼吸、血压等及病情观察、护理措施和效果、护士签名等。

According to the relevant provisions of the ministry of public health,According to the doctor's advice and illness by the nurse for critically ill patients in hospital nursing during the process of objective record.All special/dying/Seriously ill/Special treatment/Should be the strict observation of disease and the big three days of the patients should use critically ill patients with nursing records.Contents include the name of the patients/Families don't/Medical records in hospital,(Or medical record number)/Bed number/page/Record the date and time/Access liquid quantity/temperature/pulse/breathing/Blood pressure and observation on patient's illness/Nursing measures and effect/The nurse signature, etc.

　　该业内人士称，危重患者的护理记录时间更应具体到分钟，而不是出现四小时的空白。

This the personage inside course of study says,Critically ill patients with nursing record more time should be specific to minutes,Rather than appears four hours of blank.

　　

声音3 Voice 3

　　医院管理不到位 The hospital management is not in place

　　业内人士说，由于没有看到完整的病历，医院是否存在过失，这个很难判定。但是该院的医护人员工作不严谨，管理不到位，这个很明显。

The personage inside course of study says,Since there is no see complete medical history,Hospital whether there is fault,It is difficult to determine the.But the hospital medical staff work and no rigorous,Management is not in place,This obviously.

　　比如说根据有关规定，入院后72小时以内，医院针对患者的病情就要做出确诊，查不出病因，就要找其他科室会诊，或者要请上级医院来会诊，对病人进行确诊。不能到出院了，还不让病人搞清楚到底生了什么病。而小轩直到死亡时，她的死亡证明上直接导致死亡的疾病还是发烧、皮疹待查：麻疹？

For example, according to the relevant provisions,Within 72 hours after admission,The hospital according to the patient must make diagnosis,Did not find the cause,They must find other department consultation,Or to please the superior hospital to consultation,Diagnosis of a patient.Cannot come was released from the hospital,Don't let the patient to clear up exactly gave birth to what disease.And XiaoXuan until death,Her death certificate on direct cause of death by disease in this or fever/Rash in dispute:measles?

　　声音4 Voice 4

　　患儿家属称“医院在伪造病历” Families say children"The hospital in the falsify medical record"

　　“医院在伪造病历。”患儿家属说，9月10日上午12点他从医院复印回孩子的病历，在其护理记录中发现有6：50服用“布洛芬混悬液”和先后为患儿量体温。而实际上凌晨00：30后护士和医生根本就没给孩子做过任何检查，6点多孩子已经在抢救，

"The hospital in the falsify medical record."Families children said,On September 10, 12 o 'clock in the morning from his hospital copy back to the child's medical history,In the nursing record was found to have 6:50 take"Ibuprofen suspension"And successively for children's temperature.In, in the morning:After 30 nurses and doctors didn't give children do any inspection,6 point many children have in the rescue,

　　怎么可能为一个停止呼吸且即将停止心跳的患者服药降温和测量体温呢？ （东南快报 林雅 程立葳）

How could it be possible for a stopped breathing and heartbeat is to stop the patients medication cooling and measuring temperature? (Southeast express, Lin ChengLi flourishing)