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患者出院后,病历按规定时限要求回归病案室称为病历归档~([1])。归档病历反映患者接受医疗的全过程,其是医疗及相关行为如病情记录、医疗信息分析、共享、科研、保险、司法等的重要载体~([2])。医院输血管理必须体现安全、科学、合理的原则,病历是输血治疗行为可追溯性的原始依据。为更准确了解医院临床输血运行状况,促进输血管理持续改进,我院将归档病历考评运用于临床用血日常管理,现报告分析如下。
After the patient is discharged from the hospital, the medical record is returned to the medical record room according to the required time limit as the medical record ~ ([1]). Archival medical records reflect the whole process of patients receiving medical treatment, which is an important carrier of medical and related behaviors such as medical records, medical information analysis, sharing, scientific research, insurance and judiciary (2). Hospital blood transfusion management must reflect the principles of safety, science and reasonableness. Medical records are the original basis for the traceability of transfusion treatment. To better understand the clinical operation of transfusion in hospitals and to promote the continuous improvement of transfusion management, our hospital will apply the archival medical records appraisal to the daily management of clinical blood use. The report is analyzed as follows.