临床输血病历质量调查分析

调查医院输血病历存在的问题，分析不合理原因，提高临床输血质量。方法 以《病历书写基本规范》《医疗机构临床输血管理办法》《临床输血技术规范》《医院输血管理检查评分表》为依据，随机抽查我院2017年1月~12月临床用血科室的466份输血病历，对输血有关记录的完整性、输血适应证、输血不良反应进行分析。结果 共抽取病历466份，其中手术科室224份，非手术科室242份；手术科室与非手术科室输血相关记录不合格率相比较，差异有统计学意义（P＜0.05）,以输血治疗同意书记录缺陷为主；非手术科室输血合理率（93.80%）高于手术科室（89.73%），但差异无统计学意义（P＞0.05）。结论 部分临床医生对输血病历质量的重要性认识不足，医院应加强对临床输血病历质量的检查、分析和改进，加强医务人员输血知识的培训，不断提高临床输血的科学性和规范性。

Investigation and Analysis of the Quality of Medical Records of Clinical Blood Transfusion

Objective To investigate the problems existing in clinical blood transfusion medical records in hospital ,analyze unreasonable reasons and improve the quality of clinical blood transfusion. Methods "Basic Writing Norms of Medical Records""Medical Institutions Clinical Blood Management Method""Clinical Blood Transfusion Technical Specifications" and "Hospital Transfusion Management Examination Score" were used as the main basic for the survey. A total of 466 blood transfusion records of clinical blood department from January to December 2017 were randomly selected. Integrity of blood transfusion records, transfusion indications and adverse transfusion reactions were analyzed.Results A total of 466 cases were selected, including 224 surgical departments and 242 non-surgical departments;The difference between the surgical department and the non-surgical department in blood transfusion-related records was statistically significant(P<0.05), and the blood transfusion treatment consent record was the main defect; the non-surgical department blood transfusion rate(93.80%) was higher than the surgery department(89.73%), but the difference was not statistically significant (P>0.05). Conclusion Some clinicians have insufficient understanding of the importance of blood transfusion medical records. The hospital should strengthen the examination, analysis and improvement of clinical blood transfusion medical records, strengthen the training of medical personnel's blood transfusion knowledge, and continuously improve the scientific and normative clinical blood transfusion.