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目的通过对输血病历质量进行评估分析,提高临床合理用血水平和输血病历质量。方法对本院2012-2014年输血患者出院病历的抽查结果进行回顾性分析及比较。结果抽查的1 941份输血患者病历,2012-2014年临床合理用血率分别为80.7%(381/472)、98.0%(765/781)及98.7%(679/688),2013年与2012年相比显著提高(χ2=111.840,P<0.05)。2012-2014年临床输血病历中输血病程记录合格率分别为30.1%(142/472)、57.6%(450/781)及76.7%(528/688),2013年与2012年、2014年与2013年相比均有显著性差异(χ2分别为89.485、60.128,P<0.05)。结论定期分析和评估临床用血情况、抽查临床输血病历合理性、规范性,结果纳入临床科室及临床医师的考核,通过持续改进提高合理用血水平及输血病历质量,保障科学、合理、安全及有效输血。
Objective To assess and analyze the quality of blood transfusion records to improve the clinical use of blood and the quality of blood transfusion records. Methods A retrospective analysis and comparison were made between the hospital discharge records of transfusion patients during 2012-2014 in our hospital. Results The medical records of 1 941 blood transfusion patients randomly selected during the period from 2012 to 2014 were 80.7% (381/472), 98.0% (765/781) and 98.7% (679/688), respectively, in 2013 and 2012 Compared with the significant increase (χ2 = 111.840, P <0.05). The passing rates of transfusion records in clinical transfusion records from 2012 to 2014 were 30.1% (142/472), 57.6% (450/781) and 76.7% (528/688), respectively, in 2013 and 2012, 2014 and 2013 (Χ2 = 89.485, 60.128, respectively, P <0.05). Conclusion Regular analysis and assessment of clinical blood use, randomized clinical blood transfusion records were reasonable and standardized. The results were included in the evaluation of clinical departments and clinicians. Through continuous improvement and improvement of blood quality and blood transfusion records, scientific, reasonable and safe Effective transfusion.