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目的通过规范严格的输血病例管理,提高病历书写质量,为临床输血安全提供保障。方法制订输血病历检查量化评分标准,对1 009份临床输血输血病历进行评估分析。结果 2014年1月至2015年6月1 009份临床输血病史中缺陷病历数为179份(占17.7%)。随着每季度检查深入,总缺陷病历、一级缺陷病历与二级缺陷病历出现率逐渐下降,直至2015年第二季度分别降至14.2%、2.1%、1.6%(P<0.05)。然而,三级缺陷病历出现率下降不明显(P>0.05)。临床输血病历的病程记录输血指征不合理35份(占19.6%),无输注过程情况描述23份(占12.8),无临床症状描述或输血后疗效评17份(占9.5%)。结论临床输血病历检查与督导以及培训相关人员是提高输血病历质量,保障输血安全的有效手段。
Objective To improve the quality of medical record writing by standardizing strict case management of blood transfusion and provide protection for clinical transfusion safety. Methods The quantitative evaluation criteria of blood transfusion records were developed, and the clinical records of 1 009 clinical transfusion blood transfusion were evaluated. Results A total of 179 defective cases (17.7%) were recorded in the clinical transfusion history from January 2014 to June 2015. As quarterly inspections went on, the incidences of total defects, medical records of first grade and medical records of second grade decreased gradually to 14.2%, 2.1% and 1.6% respectively in the second quarter of 2015 (P <0.05). However, the incidence of tertiary defect medical records did not decrease significantly (P> 0.05). The records of clinical transfusion records recorded 35 unreasonable transfusions (19.6%), 23 without perfusion (12.8), 17 without clinical symptoms or after transfusion (9.5%). Conclusion Clinical transfusion records examination and supervision and training related personnel is to improve the quality of blood transfusion records, to ensure effective blood transfusion safety measures.