[1]徐茂云魏巍孙志东.某院临床用血病历质量分析与改进建议[J].中国卫生质量管理,2019,26(04):117-118.[doi:10.13912/j.cnki.chqm.2019.26.4.32]

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某院临床用血病历质量分析与改进建议

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 第26卷期数: 2019年04期页码: 117-118 栏目: 血液质量出版日期: 2019-07-28

作者:: 徐茂云魏巍孙志东; 解放军第960医院

关键词:: 临床用血; 输血病历

Keywords:: Blood for Clinical Use; Blood Transfusion Medical Records

DOI:: 10.13912/j.cnki.chqm.2019.26.4.32

摘要:: 目的调查临床用血病历存在问题，提出改进建议，提高病历书写质量。方法回顾性调查2017年第一季度临床用血病历，共558份。调查内容包括临床用血管理制度、输血前相关检查、输血记录单等。结果558份病历中，不规则抗体报告单缺失76份，占13.62%；输血病程记录缺失或不规范142份，占25.4%；无输血记录单或填写不规范53份，占9.5%；无输血疗效评价表或要素不全78份，占14.0%。结论医院应严格进行报告单管理，加强临床用血知识培训，强化监督检查，以促使临床用血管理水平持续提升。

Abstract:: ObjectiveTo investigate the problems and improve the quality of medical records of clinical blood use.MethodsA total of 558 blood transfusion records were retrieved by retrospective survey between January and March 2017, the survey included blood transfusion management system, pre-transfusion test, and blood transfusion record sheet etc. Results Among the 558 medical records, 76 records lacked of irregular antibody report,accounted for 13.62%; the transfusion progress note of 142 records were missing or irregular, accounting for 25.4%; the blood transfusion of 53 records were lacked or nonstandard, accounted for 9.5%;the blood transfusion evaluation form of 78 records were lacked or uncomplete, accounted for 14.0%.Conclusion The hospital should strengthen the management of report forms, increase training efforts and enhance supervision and inspection, so as to improve the management level of blood transfusion.

参考文献/References:

［1］郑萍，张静，蔡莉，等.临床输血病历质量调查分析［J］.中国输血杂志，2012，25（3）：269-271.

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更新日期/Last Update: 2019-07-28