621份临床输血病案的质量调查

目的了解输血病历中存在的问题，规范临床输血病历。方法随机抽查621份我院自2010年1月至2012年12月归档的输血病案。检查病案首页、输血治疗知情同意书、输血前检验、输血适应证、输血护理记录、输血不良反应、输血评估及疗效评价7个项目，计算缺陷率和合格率。结果188份输血病案存在不同程度的缺陷，缺陷病案比例为30．2％，其中43份病案存在2处以上的缺陷，缺陷病案比例为6．92％，共缺陷352次，进行各项不合格率统计。结论输血病案存在许多缺陷，医院必须加强对输血工作的管理，规范填写输血病历记录，提高输血病历记录质量，确保输血安全。

Quality Survey on 621 Cases of Clinical Blood Transfusion Medical Records

Objectives To acquire the problems existing in blood transfusion medical records and standardize the clinical blood transfusion medical records. Methods 621 cases of blood transfusion medical records from January 2010 to December 2012 in our hospital were randomly inspected. Seven items were inspected such as the home pages of medical records, blood transfusion treatment informed con- sent, test before blood transfusion, as well as indications, nursing records, adverse reaction and therapeutic efficiency evaluation of blood transfusion, then calculated the defect rate and qualified rate. Results There were defects of varying degrees existing in 188 cases of blood transfusion medical records and the proportion of defective records was 30.2 %. In which 43 cases had more than two defects, 352 defects were found totally and the proportion of defective records was 6.92 %. The unqualified rate of each project were counted. Conclusions In the blood transfusion medical records, there were lots of defects existing. In order to ensure the safety of blood transfusion, the hospital must strengthen the management of blood transfusion, standardize the blood transfusion medical records and improve the quality of the medical records at the same time.