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目的了解输血病历中存在的问题,规范和提高输血病历的质量。方法对本院2010年1月～2011年12月临床用血科室的356份临床输血病历做调查分析,内容包括:《输血治疗同意书》、《输血申请单》、输血前检查、输血前评估、输血治疗过程记录、输血后疗效评价以及输血过程护理人员的病程观察记录等8个方面。结果本院近2年的临床输血病历的书写不合格率达到21.35%(76/356),手术类科室输血病历不合格率达到25.20%(63/250),非手术类科室输血病历不合格率达到12.26%(13/106)。结论据此调查统计分析,可制定相应整改措施,规范病历书写和提高输血病历质量。
Objective To understand the existing problems in transfusion medical records, regulate and improve the quality of transfusion medical records. Methods A total of 356 clinical transfusion records of clinical department of blood department from January 2010 to December 2011 in our hospital were investigated and analyzed. The contents included “consent of transfusion”, “blood transfusion request form”, pre-transfusion examination, pre-transfusion assessment , Records of transfusion during treatment, efficacy evaluation after blood transfusion, and records of the course of treatment of nurses during blood transfusion. Results In the recent 2 years, the clinical failure rate of transfusion medical records reached 21.35% (76/356). The failure rate of transfusion medical records in surgical departments reached 25.20% (63/250). The non-surgical transfusion records failed in non-surgical departments Reaching 12.26% (13/106). Conclusions According to the survey statistical analysis, we can formulate corresponding rectification measures, standardize medical record writing and improve the quality of blood transfusion records.