Evaluation and analysis of quality of clinical transfusion medical records
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摘要: 目的:探讨通过提高临床输血病历的书写质量,不断完善和细化医院临床用血的管理制度,从而达到提高临床输血安全和节约临床用血的目的。方法:严格按照医院对临床输血病历的标准对本院近一年内输血病历中的书写质量问题进行统计分析。结果:输血病历进行评估后,其存在显著性差异的病历质量问题有五点:"申请单项目缺项"占总输血病历数的15.6%;"申请血液种类或数量不规范"占21.3%;"大量输血审批单欠缺或缺项"占24.1%;"输血前未对相应的输血指征进行评估"占27.1%;"输血后效果无评估"占29.4%。结论:有效提高输血病历的书写质量,制定和完善临床科室合理用血管理制度,建立行之有效的临床病历评估体系及管理模式,规范临床用血行为,真正提高临床输血安全和输血疗效。Abstract: Objective: To statistically analyze the existence of quality defects and problems in blood transfusion medical records in our hospital in recent year,discuss improving writing quality of the clinical blood transfusion record,and constantly improve and refine hospital management system of clinical blood transfusion,so as to improve the safety and saving of the clinical blood transfusion.Method: According to clinical blood transfusion standard of the hospital,ten aspects and 16 points in writing quality problems of the clinical blood transfusion record in recent years were statistically analyzed.Result: After evaluation of the blood transfusion record,there were significant differences in the clinical blood transfusion record within five points:the number of "items missing of application" was the total 15.6% of the medical records of the transfusion;the number of "blood type or quantity not standardized of application" was the total 21.3% of the medical records of the transfusion;the number of "lack or absence approval of massive transfusion" was the total 24.1% of the medical records of the transfusion;the number of "no evaluation before blood transfusion" was the total 27.1% of the medical records of the transfusion;the number of "no evaluation of post-transfusion" was the total 29.4% of the medical records of the transfusion.Conclusion: To effectively improve writing quality of blood transfusion medical record,develop and improve the clinical rational of the clinical blood transfusion,and establish the effective medical evaluation system and management mode could regulate the scientific clinical blood transfusion,and really improve clinical blood transfusion safety and its clinical efficacy.
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Key words:
- clinical transfusion medical records /
- writing quality /
- transfusion safety /
- evaluation
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