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目的分析输血病案中存在的缺陷,规范和提高临床输血病历书写质量,防范临床用血医患纠纷。方法检查某院2016年1月1日至2016年12月31日住院患者输血病案2268份,并对其中675份缺陷病案进行调查分析。结果输血病案缺陷率为33.5%,主要项目缺陷分别为:输血知情同意书缺陷占8.7%、住院病案首页缺陷占12.4%、病程记录缺陷占16.2%、疗效评估缺陷27.8%、输血记录单缺陷占38.5%。结论临床输血病案中存在诸多缺陷,需进一步强化医务人员法律意识,规范书写标准,确保输血流程的安全性和科学性。
Objective To analyze the defects in transfusion cases, standardize and improve the writing quality of clinical transfusion records, and prevent the disputes of clinical and medical patients. Methods A total of 2,268 inpatient transfusion cases from January 1, 2016 to December 31, 2016 in a hospital were examined, and 675 of them were investigated. Results The defect rate of blood transfusion was 33.5%. The main defects of the transfusion were as follows: 8.7% of the informed consent of transfusion, 12.4% of the first page of the inpatient medical record, 16.2% of the recorded disease course defects, 27.8% of the curative effect evaluation defects, 38.5%. Conclusion There are many shortcomings in clinical transfusion cases, which require further strengthening of legal awareness of medical personnel, standardization of writing standards and ensuring the safety and scientificity of blood transfusion.