摘要
目的 通过分析临床输血病案质量,提出改进措施,提高输血病案规范化水平.方法 建立输血病案质量考核指标,督导检查2016年1月1日-2018年12月31日临床输血病案共计1248份.统计每份病案输血前检查、输血知情同意书、输血适应症、输血病程记录情况等,分析不合格病案原因和构成.结果 输血病案合格率逐年增高.合格率由2016年的79.3%上升到2018年的85.9%.以2018年为例,输血病案常见不合格项依次为无输血后效果评价、无输血过程记录、无输血适应症,不合格率分别为5.1%、4.1%、4.1%.不合格率较2016年和2017年均明显下降.结论 建立输血病案质量考核指标,总结管理经验,持续对临床输血病案进行检查与督导可有效提高临床输血病案质量.
Objectives By analyzing the quality of clinical transfusion medical records,summarizing the management experience,proposing improvement measures,improving the standardization level of blood transfusion medical records.Methods To establish the quality assessment index of blood transfusion medical records,1248 clinical blood transfusion records in the hospital from January 1st,2016 to December 31,2018 was conducted.Statistical analysis of pre-transfusion examination,informed consent forms,blood transfusion indications,transfusion history records,recording the number of unqualified cases and analyzing the constituent ratio.Results The rate of qualified medical records increased year by year.The qualified rate increased from 79.3%in 2016 to 85.9%in 2018.In 2018,for example,among them,The common unqualified items in the medical history of blood transfusion were no post-transfusion evaluation records、no transfusion record、no indications for blood transfusion.The unqualified rate was 5.1%,4.1%and 4.1%respectively.Compared with 2016 and 2017,the unqualified rate decreased significantly.Conclusions To establish the quality assessment index of blood transfusion medical records,verification and supervision of clinical blood transfusion cases could effectively improve the quality of clinical blood transfusion cases.
作者
赵世巧
戚世娟
蒋琳华
杨晶
Zhao Shiqiao;Qi Shijuan;Jiang Linhua;Yang Jing(Department of Blood Transfusion,Chongqing Traditional Chinese Medicine Hospital,Chongqing 400021,China)
出处
《中国病案》
2019年第9期14-17,共4页
Chinese Medical Record
关键词
输血病案
考核指标
评价
Transfusion records
Assessment index
Evaluation
作者简介
通信作者:戚世娟
