临床输血病历质量精准评估与分析

发布时间：2019-06-10 21:10

【摘要】：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%(P0.05)。然而,三级缺陷病历出现率下降不明显(P0.05)。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。
[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.
【作者单位】：邯郸市第一医院输血科;秦皇岛市中心血站;
【分类号】：R457.1

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