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目的加强临床输血病历规范化管理,提高输血病历质量,防范临床用血医患纠纷。方法以临床输血病历的有关规定为依据,采取随机抽查的方法,对我院2012年258份输血病历按季度进行检查统计分析。结果 258份临床输血病历中缺陷病历128份,缺陷率为49.6%,其中用血医嘱不合格病历44份,占17%,临床输血知情同意书不合格病历88份,占34.1%,输血病程记录不合格病历229份,占88.8%。结论需要加强对输血病历的质量管理,有针对地对出现的主要问题制定相应的整改措施,提高病历质量,以降低医疗风险。
Objective To strengthen the standardized management of clinical blood transfusion records, improve the quality of blood transfusion records and prevent clinical disputes with blood transfusion patients. Methods Based on the relevant provisions of clinical transfusion medical records, random sampling method was used to check 258 cases of blood transfusion records in our hospital on a quarterly basis. Results A total of 128 medical records of transfusions were recorded, with a defect rate of 49.6%. Among them, 44 were false medical records, accounting for 17% of the total, 88 were unqualified clinical transfusion records, accounting for 34.1% 229 cases of unqualified medical records, accounting for 88.8%. Conclusion The quality management of blood transfusion records needs to be strengthened. Corresponding corrective measures should be formulated for the main problems that occur, and the medical record quality should be improved so as to reduce the medical risks.