临床用血相关记录缺陷分析及管理

目的分析临床输血相关记录的缺陷,提高临床用血医疗文书的完整性和内涵质量。方法对1252份归档输血病案的病案首页填写、临床输血治疗知情同意书、输血前检验项目报告单、医嘱、输血病程记录、输血记录单、术中输血麻醉和护理记录进行检查,对缺陷次数和存在的问题进行分析。结果缺陷率最高的是输血病程记录（43.1%）,其次分别是临床输血治疗知情同意书（36.7%）、病案首页（21.8%）、医嘱（28.0%）,输血前传染病检验报告单缺陷率为0。主要存在的缺陷问题是病案首页填写内容与实际输血量或输血成分不一致、临床输血治疗知情同意书中未记录输血成分、输血医嘱中未注明输血成分或不准确、无输血病程记录或记录不完整、输血记录单不全。结论医疗机构要充分发挥部门职能,加强输血知识培训和各质控环节的监督作用,进一步强化医护人员对临床用血医疗文书内涵质量的重视程度,促进临床用血医疗文书书写质量与管理标准化、规范化。

Defects Analysis and Management on Related Records of Clinical Use of Blood

Objective To analyze the defects in the related records of clinical use of blood,and improve the integrity and quality of related medical documents.Methods To conduct an examination to 1225 cases of archived medical records of blood transfusion,and inspect the filling in of home pages,informed consent of blood transfusion treatment,inspection items reports before transfusion,doctors＇ advice,transfusion progress note,transfusion record list,anesthesia and nursing records during the operation,then analyzed the times of defects and existing problems.Results The highest defects rate was transfusion progress note（43.1%）,secondly were informed consent of blood transfusion treatment（36.7%）,home pages of medical records（21.8%）,doctors＇ advice（28.0%）,and the defect rate of infection diseases inspection items before transfusion was zero.The main defects problems existing were inconformity of filling content in home pages with actual transfusion volume and component,without recording transfusion component in the informed consent of blood transfusion treatment,without indicating transfusion component or in accurate records in the transfusion doctor＇s advice,without transfusion progress note or incomplete recording,and incomplete transfusion records notes.Conclusions The medical institutions should give full play to their function to strengthen transfusion knowledge training and the supervisory role in each link of quality control,further intensify the importance of the quality of clinical medical documents of blood transfusion among doctors and nurses,and promote the standardization and normalization of the quality and management of the clinical medical documents of blood transfusion.