【摘要】：目的通過規(guī)范嚴(yán)格的輸血病例管理,提高病歷書寫質(zhì)量,為臨床輸血安全提供保障。方法制訂輸血病歷檢查量化評(píng)分標(biāo)準(zhǔn),對(duì)1 009份臨床輸血輸血病歷進(jìn)行評(píng)估分析。結(jié)果 2014年1月至2015年6月1 009份臨床輸血病史中缺陷病歷數(shù)為179份(占17.7%)。隨著每季度檢查深入,總?cè)毕莶v、一級(jí)缺陷病歷與二級(jí)缺陷病歷出現(xiàn)率逐漸下降,直至2015年第二季度分別降至14.2%、2.1%、1.6%(P0.05)。然而,三級(jí)缺陷病歷出現(xiàn)率下降不明顯(P0.05)。臨床輸血病歷的病程記錄輸血指征不合理35份(占19.6%),無(wú)輸注過程情況描述23份(占12.8),無(wú)臨床癥狀描述或輸血后療效評(píng)17份(占9.5%)。結(jié)論臨床輸血病歷檢查與督導(dǎo)以及培訓(xùn)相關(guān)人員是提高輸血病歷質(zhì)量,保障輸血安全的有效手段。
[Abstract]:Objective to improve the quality of medical record writing by standardizing and strictly managing blood transfusion cases, and to provide guarantee for clinical blood transfusion safety. Methods the quantitative scoring standard of blood transfusion medical records was established, and 1 009 clinical blood transfusion medical records were evaluated and analyzed. Results from January 2014 to June 2015, 179 (17.7%) of the 1 009 clinical transfusion history cases were defective. With the deepening of quarterly examination, the occurrence rate of primary defect medical record and secondary defect medical record decreased gradually, and decreased to 14.2%, 2.1% and 1.6% respectively in the second quarter of 2015 (P 0.05). However, the occurrence rate of tertiary defect medical records did not decrease significantly (P 0.05). The course of clinical blood transfusion record was unreasonable in 35 cases (19.6%), no infusion process description in 23 cases (12.8), no clinical symptom description or post-transfusion curative effect evaluation in 17 cases (9.5%). Conclusion the examination and supervision of clinical blood transfusion medical records and the training of related personnel are effective means to improve the quality of blood transfusion medical records and ensure the safety of blood transfusion.
【作者單位】： 邯鄲市第一醫(yī)院輸血科;秦皇島市中心血站;
【分類號(hào)】：R457.1

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