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目的为医院的病案质量管理和医疗安全提供参考。方法制定输血病案专项检查标准,对320份输血病案进行质量分析。结果病案合格率:病案首页90.93%、输血同意书91.87%、输血前化验结果83.75%、输血指征92.18%、成份输血比例91.25%、输血观察记录77.50%。结论输血病案质量直接影响病案内涵和医疗质量与安全,医院应当加强输血病案质量管理,确保医疗安全,避免医疗纠纷。
Objective To provide reference for hospital medical record quality management and medical safety. Methods To develop a special inspection standard for blood transfusion cases and conduct quality analysis on 320 cases of transfusion cases. Results The rate of medical record was 90.93% on the first page of medical record, 91.87% on blood transfusion consent, 83.75% on transfusion, 92.18% on transfusion, 91.25% on blood transfusion and 77.50% on blood transfusion. Conclusion The quality of blood transfusion cases directly affects the connotation of medical records and the quality and safety of medical services. The hospital should strengthen the quality management of blood transfusion medical records to ensure medical safety and avoid medical disputes.