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目的完善输血病历质量,规范临床输血治疗行为。方法每月检查2014年输血病历2055份,以《病历书写基本规范》、《临床输血技术规范》等为标准,进行质量检查,针对存在问题,提出改进输血病历质量办法。结果 2055份输血病历中合格率37.47%,上半年合格率33.39%,经过干预,下半年合格率43.88%,两者比较差异具有统计学意义(P<0.05),输血病历质量改进显著;手术科室合格率(34.58%)明显低于非手术科室(41.32%),两者比较差异具有统计学意义(P<0.05)。不合格病历中,输血治疗知情同意书缺陷问题最为突出,占37.85%。不合理输血占6.67%。结论持续改善输血病历质量,提高医务人员法律意识,有利于促进规范输血管理,保证医疗安全。
Objective To improve the quality of blood transfusion records and standardize the clinical transfusion treatment. Methods A total of 2,055 medical records of transfusions in 2014 were inspected every month. Quality control was based on the basic norms of medical record writing and technical specifications of clinical transfusion, and the methods of improving the quality of transfusion medical records were put forward according to the existing problems. Results The qualified rate of transfusion medical records was 37.47% in 2055 cases, and the pass rate in the first half of the year was 33.39%. After the intervention, the passing rate in the second half of the year was 43.88%, with statistical significance (P <0.05) The pass rate (34.58%) was significantly lower than that of the non-surgical department (41.32%), the difference was statistically significant (P <0.05). Among the unqualified medical records, the flaws in the informed consent form for blood transfusion were the most prominent, accounting for 37.85%. Unreasonable transfusion accounted for 6.67%. Conclusion The continuous improvement of the quality of blood transfusion records and the improvement of legal awareness of medical staff are helpful to regulate the management of blood transfusion and ensure medical safety.