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目的:了解HIS系统输血模块的启用与改进对输血文档填写质量的作用,确保临床科学、合理、规范化安全输血[1]。方法:回顾性分析武汉市第一医院2012-05-2012-10共计3 347份输血申请单,按HIS系统输血模块少部分科室启用,HIS系统输血模块全面启用但未对临床培训及HIS系统输血模块全面启用且对临床培训后分为部分启用组,未培训组,培训组,分别对各组的电子申请单覆盖率及文档填写质量进行相关分析,评价医院输血管理系统的启用后和经过输血科培训后各科室文档电子化的覆盖及输血申请单质量情况。结果:HIS系统输血模块上线后,电子输血申请单覆盖率由18.09%升至49.17%,经过输血科培训后电子输血申请单上升至78.4%;输血申请单合格率由51.7%升至81.40%,经过输血科培训后合格率升至93.0%,两者呈现正相关关系(R=0.99)。研究发现输血申请单的合格率上升主要是由于电子病历的推广所导致的。结论:随着HIS系统输血模块的上线,输血申请单逐步电子化,不合格率也逐步降低,有助于进一步规范输血、用血安全,减少输血医疗纠纷。
Objective: To understand the function of blood transfusion module of HIS system and improve the quality of blood transfusion documents, to ensure clinical science, reasonable, standardized and safe transfusion [1]. Methods: A retrospective analysis of Wuhan City First Hospital from 2012-05 to 2012-10 totaled 3 347 blood transfusion requests. A few departments of HIS transfusion module were activated. The HIS transfusion module was fully activated but no clinical training and HIS transfusion The module is fully enabled and after clinical training, it is divided into some enabled groups, untrained groups and training groups. The coverage of electronic application forms and the quality of documents are analyzed respectively. The hospital blood transfusion management system is enabled and transfused After the training of various departments of the electronic documentation of the coverage and blood transfusion request form quality. Results: After the blood transfusion module of HIS system went online, the coverage rate of transfusion application rose from 18.09% to 49.17%, and the number of transfusion transfusion requests rose to 78.4% after blood transfusion training. The passing rate of blood transfusion application rose from 51.7% to 81.40% After the blood transfusion department training rate rose to 93.0%, the two showed a positive correlation (R = 0.99). The study found that the increase in the passing rate of transfusion requests was mainly due to the promotion of electronic medical records. Conclusion: With the on-line transfusion module of HIS system, the blood transfusion request form is gradually electronicized, and the unqualified rate is also gradually reduced, which helps to further regulate blood transfusion, blood safety and reduce transfusion medical disputes.