临床输血病历质量调查分析(1)
摘 要：目的 调查医院输血病历存在的问题，分析不合理原因，提高临床输血质量。方法 以《病历书写基本规范》《医疗机构临床输血管理办法》《临床输血技术规范》《医院输血管理检查评分表》为依据，随机抽查我院2017年1月～12月临床用血科室的466份输血病历，对输血有关记录的完整性、输血适应证、输血不良反应进行分析。结果 共抽取病历466份，其中手术科室224份，非手术科室242份；手术科室与非手术科室输血相关记录不合格率相比较，差异有统计学意义(P<0.05)，以输血治疗同意书记录缺陷为主；非手术科室输血合理率(93.80%)高于手术科室(89.73%)，但差异无统计学意义(P>0.05)。结论 部分临床医生对输血病历质量的重要性认识不足，医院应加强对临床输血病历质量的检查、分析和改进，加强医务人员输血知识的培训，不断提高临床输血的科学性和规范性。
关键词：临床输血；病历质量；输血记录
中图分类号：R457.1 文献标识码：A DOI：10.3969/j.issn.1006-1959.2018.23.038
, http://www.100md.com
文章编号：1006-1959(2018)23-0133-03
Abstract：Objective To investigate the problems existing in clinical blood transfusion medical records in hospital ，analyze unreasonable reasons and improve the quality of clinical blood transfusion. Methods "Basic Writing Norms of Medical Records""Medical Institutions Clinical Blood Management Method""Clinical Blood Transfusion Technical Specifications" and "Hospital Transfusion Management Examination Score" were used as the main basic for the survey. A total of 466 blood transfusion records of clinical blood department from January to December 2017 were randomly selected. Integrity of blood transfusion records， transfusion indications and adverse transfusion reactions were analyzed.Results A total of 466 cases were selected， including 224 surgical departments and 242 non-surgical departments；The difference between the surgical department and the non-surgical department in blood transfusion-related records was statistically significant(P<0.05)， and the blood transfusion treatment consent record was the main defect； the non-surgical department blood transfusion rate(93.80%) was higher than the surgery department(89.73%)， but the difference was not statistically significant (P>0.05). Conclusion Some clinicians have insufficient understanding of the importance of blood transfusion medical records. The hospital should strengthen the examination， analysis and improvement of clinical blood transfusion medical records， strengthen the training of medical personnel's blood transfusion knowledge， and continuously improve the scientific and normative clinical blood transfusion.
, http://www.100md.com
Key words：Clinical blood transfusion；Medical record quality；Blood transfusion record
臨床输血(clinical blood transfusion)是抢救生命、治疗疾病的重要医疗手段之一，但同时也是一把双刃剑，在治疗患者的同时，也会带来巨大的输血风险[1]。病历是临床治疗疾病、抢救患者实施过程的最原始文字记录，在输血治疗中，输血病历记录不及时、不准确、不真实及医护记录不一致等情况将可能埋下医疗纠纷隐患。认真做好输血病历的规范化工作，不仅是安全输血的需要，也是对患者、医护人员、医院及血站合法权益的保障。为了解本院临床输血病历情况，对本院466份输血病历进行调查分析，现将结果报告如下。
1资料与方法
1.1一般资料 抽取2017年1月～12月川北医学院附属医院临床用血科室住院患者输血病历共466份，含手术科室(包括外科、产科等16个科室)输血病历224份、非手术科室(包括血液内科、消化内科、感染科等17个科室) 输血病历242份。, http://www.100md.com(凌止发 李小平 罗巧彦)
关键词：临床输血；病历质量；输血记录
中图分类号：R457.1 文献标识码：A DOI：10.3969/j.issn.1006-1959.2018.23.038
, http://www.100md.com
文章编号：1006-1959(2018)23-0133-03
Abstract：Objective To investigate the problems existing in clinical blood transfusion medical records in hospital ，analyze unreasonable reasons and improve the quality of clinical blood transfusion. Methods "Basic Writing Norms of Medical Records""Medical Institutions Clinical Blood Management Method""Clinical Blood Transfusion Technical Specifications" and "Hospital Transfusion Management Examination Score" were used as the main basic for the survey. A total of 466 blood transfusion records of clinical blood department from January to December 2017 were randomly selected. Integrity of blood transfusion records， transfusion indications and adverse transfusion reactions were analyzed.Results A total of 466 cases were selected， including 224 surgical departments and 242 non-surgical departments；The difference between the surgical department and the non-surgical department in blood transfusion-related records was statistically significant(P<0.05)， and the blood transfusion treatment consent record was the main defect； the non-surgical department blood transfusion rate(93.80%) was higher than the surgery department(89.73%)， but the difference was not statistically significant (P>0.05). Conclusion Some clinicians have insufficient understanding of the importance of blood transfusion medical records. The hospital should strengthen the examination， analysis and improvement of clinical blood transfusion medical records， strengthen the training of medical personnel's blood transfusion knowledge， and continuously improve the scientific and normative clinical blood transfusion.
, http://www.100md.com
Key words：Clinical blood transfusion；Medical record quality；Blood transfusion record
臨床输血(clinical blood transfusion)是抢救生命、治疗疾病的重要医疗手段之一，但同时也是一把双刃剑，在治疗患者的同时，也会带来巨大的输血风险[1]。病历是临床治疗疾病、抢救患者实施过程的最原始文字记录，在输血治疗中，输血病历记录不及时、不准确、不真实及医护记录不一致等情况将可能埋下医疗纠纷隐患。认真做好输血病历的规范化工作，不仅是安全输血的需要，也是对患者、医护人员、医院及血站合法权益的保障。为了解本院临床输血病历情况，对本院466份输血病历进行调查分析，现将结果报告如下。
1资料与方法
1.1一般资料 抽取2017年1月～12月川北医学院附属医院临床用血科室住院患者输血病历共466份，含手术科室(包括外科、产科等16个科室)输血病历224份、非手术科室(包括血液内科、消化内科、感染科等17个科室) 输血病历242份。, http://www.100md.com(凌止发 李小平 罗巧彦)