输血申请单与临床输血记录在三级综合医院评审中的意义

目的：结合国家卫生部《三级综合医院评审标准（2011版）》实施细则有关输血管理与持续改进中对临床输血病历记录的要求,探讨临床输血申请单审核、临床输血病历规范化管理的必要性,以提高临床输血的质量,确保临床输血的安全有效。方法：针对本院2012年1月—2012年6月住院患者临床输血申请单2828份及抽查输血病历1450份中存在的主要问题进行分析。结果：在2828份输血申请单中有529份填写不合格,占总数的18.7%;抽查输血病历1023份,占输血病历的70.5%,不合格病例172份,占16.8%。结论：完善临床用血的组织管理,制定临床用血记录规章制度与流程,加强临床医护人员临床输血知识培训,规范临床输血病历记录,定期进行临床输血病历检查,保障临床用血安全有效的进行。

Role of Blood Transfusion Application and Records in Overview of First Class Hospitals

Objective ： According to the details for the Criteria for Overviewing the First C/ass Hospitals （ Edition 2011 ）launched by the Ministry of Health which requires the hospitals to improve and keep the record of blood transfusion for all patients, we tried a standard processing for blood transfusion in our hospital including application, review and record of blood transfusion, which significantly increased the quality and safety of blood transfusion. Methods ： We checked a total of 2828 applications and 1450 clinical records for blood transfusion in our hospital during January-June, 2012 and analyzed the problems existed in the applications and clinical records. Resuhs ： A total of 529 applications were not filled as required, accounting for 18.7% of the total applications. There were 172 clinical records unmatched the requirement for blood transfusion clinical record, accounting for 16.8% of the checked records （ n=1023 ）. Conclusions ： For safely and efficiently using blood for transfusion, the hospital needs to improve its administration, to detail the rules for filling and processing application and clinical records, to train the physicians knowledge of blood transfusion and regularly to check the clinical records.