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目的 :加强医院病历质量规范管理,分析输血病历存在的问题,改进和完善输血病历的质量,以提高临床输血的安全性。方法:根据《病历书写基本规范》、《临床输血技术规范》等相关制度要求,制定输血病历质量检查标准,对3年中所有归档的1 856份输血病历进行质量分析,从中总结输血病历中存在的不足,并提出防范的相关对策。结果:输血病历质量符合检查标准的占83.1%(1 543/1 856),不符合检查标准占16.9%(313/1 856),不达标的输血病历在逐年下降;非手术科室输血病历达标率明显高于手术科室,两者比较有统计学差异(P<0.001);而313份不合格输血病历中输血治疗病程记录不合格最为明显,占64.5%(202/313),其次“输血治疗同意书”不合格率为29.4%(92/313)。结论:建议定期开展输血病历质量督查,有效提高输血病历质量,规范输血管理,确保医疗安全,避免医疗纠纷。
OBJECTIVE: To strengthen the management of hospital medical records quality standards, analyze the existing problems in transfusion medical records, improve and perfect the quality of transfusion medical records so as to improve the safety of clinical transfusion. Methods: According to the requirements of the “Basic Norms of Medical Records Writing” and “Technical Specifications of Clinical Transfusion”, the quality standard of transfusion medical records was formulated. The quality of transcripts of 1 856 transfusions recorded in all 3 years was analyzed. Of the deficiencies, and put forward preventive measures. Results: 83.1% (1 543/1 856) of the transfused medical records met the test criteria, 16.9% (313/1 856) did not meet the test criteria, and the number of non-compliance transfusion cases decreased year by year. The blood transfusion records of non- (P <0.001). However, the records of blood transfusion in 313 unqualified transfusions were the most unacceptable, accounting for 64.5% (202/313), followed by “Transfusion Therapy Consent ”The failure rate was 29.4% (92/313). Conclusion: It is recommended that the quality of blood transfusion records should be regularly checked to effectively improve the quality of blood transfusion records, regulate blood transfusion management, ensure medical safety and avoid medical disputes.