某三甲医院720份临床输血病历病程记录合格性调查

目的分析某三甲医院720份临床输血病历病程记录合格性,为提高临床输血治疗质量提供借鉴。方法随机抽取本院2015-2017年接受输血治疗的720例患者的输血病历,分析病程记录合格性。结果 2015、2016、2017年输血前、中、后的病历病程记录不合格率比较,组间差异均显著(P<0.05);2015、2016年,非手术科室输血病历合格率均明显高于同年度手术科室(P<0.05)。结论临床输血病历病程记录不规范问题虽然逐年有所改善,但仍然较为常见,手术科室输血病历不合格问题较为突出,应引起高度重视。

Investigation on qualification of 720 cases of clinical transfusion medical records in a top three hospital

Objective To analyze the qualification of 720 cases of clinical blood transfusion medical records in a three Grade A hospital, and to provide reference for improving the quality of clinical blood transfusion treatment. Methods The blood transfusion medical records of 720 patients who received blood transfusion in our hospital from 2015 to 2017 were randomly selected and the qualification of the progress note was analyzed. Results The rates of unqualified medical records before, during and after blood transfusion in 2015, 2016 and 2017 were significantly different among groups(P<0.05). In2015 and 2016, the qualified rates of transfusion medical records in non-surgical departments were significantly higher than those in operation departments in the same year(P<0.05). Conclusion Although the irregularity of clinical blood transfusion medical records has been improved year by year, it is still more common. The problem of unqualified transfusion medical records in operation departments is more prominent, which should be paid great attention to.