946份临床输血病历质量调查分析.docVIP

精品论文 参考文献 946份临床输血病历质量调查分析 胡润琴 　　(临沧市人民医院输血科 云南 临沧 677000) 　　【摘要】 目的:通过调查我院住院患者临床输血病历，了解病历中存在的问题,以规范和提高临床输血病历的质量。方法:输血科工作人员随机抽取我院2013年临床用血科室住院患者病历946份做调查分析，内容包括：《输血治疗同意书》、《输血申请单》、输血前免疫学检查、输血前评估、输血后疗效评价、输血治疗过程记录、输血不良反应回报以及大量用血的审批等8个方面。结果:我院2013年临床输血病历书写不合率为22.73%（215/946），手术科室输血病历不合格率为30.55%（172/563），非手术科室输血病历不合格率为11.23%（43/383）。结论:输血病历书写的不够规范、完整，部分临床医生对输血病历质量的重要性认识不足,应通过对输血病历的标准化和规范化培训,增强医护人员对临床输血风险的认识,提高临床输血的安全性、合理性，减少医疗纠纷的发生。 　　【关键词】 临床输血；病历质量；规范化和标准化 　　【中图分类号】R197.3 【文献标识码】A 【文章编号】2095-1752（2015）12-0366-03 　　946 clinical blood transfusion medical record quality investigation and analysis Hu Runqin 　　Peoples Hospital of Lincang City . Yunnan Lincang 677000,China 　　【Abstract】Methods Blood transfusion department staff in our hospital from 2013, a random sample of clinical blood use department in the hospital medical records of 946 patients with analysis of the survey, include: the blood transfusion treatment agreement, application form for blood transfusion, blood transfusion immunology examination, blood transfusion before the assessment, curative effect evaluation after blood transfusion, blood transfusion treatment process records, return and a large amount of blood transfusion reactions, eight aspects such as the examination and approval. Results The clinical blood transfusion in our hospital from 2013 medical record writing out rate was 22.73% (215/946), the operation department of blood transfusion medical records not qualified rate was 30.55% (172/563), non-surgical transfusion department records not qualified rate was 11.23% (43/383). Conclusion Blood transfusion medical records written specifications, complete enough, some clinicians insufficient understanding of the importance of blood transfusion medical record quality, standardization and standardization of medical records should be based on the blood transfusion training, enhance staff awareness of the risk of clinical blood transfusion, to improve the safety