2016-2018年河北医科大学第四医院输血病历质量调查分析

目的 调查医院输血病历中存在的问题，分析不合理因素，提高输血病历质量，为安全输血提供保障。 方法 根据《医疗机构临床用血管理办法》《临床输血技术规范》的相关要求，制定临床输血病历评价标准，随机抽取有输血的临床科室输血病历1 183份，从输血前检测、输血知情同意书、输血适应症评估、病程记录、输血过程管理、输血不良反应上报及大量输血回报进行评价。 结果 抽查病历1 183份，其中缺陷病历203份，占17.16%。2016-2018年不合格病历明显下降，差异有统计学意义（P＜0.05）。2016年的输血缺陷病历各检查项占比均较多，缺陷病例比例也较高，随着输血病历检查深入，缺陷病历不合格项逐年减少，缺陷病例比例也逐渐减少，差异有统计学意义（P＜0.05），到2018年不合格项主要集中在输血适应症评估上（3.96%）。抽查病历中含有非手术科室病历537份，其中缺陷病历55份，占10.24%。手术科室病历646份，其中缺陷病历数148份，占22.91%。2016年、2017年手术科室与非手术科室合格病历比例的比较差异有统计学意义（P＜0.05）。 结论 通过对输血病历的检查，使全院的输血病历得到提高，但依旧存在一定的问题，应加强临床医生的培训，进一步提高输血病历的质量。

Quality of blood transfusion medical records in the Fourth Hospital of Hebei Medical University from 2016 to 2018

Objective〖HTSS〗To investigate the problems existing in hospital blood transfusion records, analyze the unreasonable factors, improve the quality of blood transfusion records, and provide guarantees for safe blood transfusion. 〖WTHZ〗Methods〖HTSS〗According to “Management of blood for clinical use in medical institutions” and “Technical specifications for clinical transfusion”, develop evaluation criteria for clinical blood transfusion records, 1 183 blood transfusion records were randomly selected from clinical departments with blood transfusion, pre-transfusion testing, informed consent, indication assessment, course record, management of transfusion process, adverse reaction report and return of large amount of transfusion were evaluated.〖WTHZ〗Results〖HTSS〗A total of 1 183 medical records were randomly examined, among which 203 were defective, accounting for 17.16%. From 2016 to 2018, unqualified medical records decreased significantly, and the difference was statistically significant(P＜0.05). In 2016, the examination items of blood transfusion defect medical records accounted for a large proportion, and the proportion of defect cases was also relatively high. With the in-depth examination of blood transfusion medical records, the unqualified items in defect medical records decreased year by year, and the proportion of defect cases gradually decreased, with statistically significant difference(P＜0.05). By 2018, the unqualified items mainly focus on the evaluation of indications for blood transfusion(3.96%). Among the sampled medical records, 537 were from non-surgical departments, among which 55 were defective, accounting for 10.24%. There were 646 medical records in surgical departments, including 148 defective medical records, accounting for 22.91%. There were statistically significant differences in the proportion of qualified medical records between surgical departments and non-surgical departments in 2016 and 2017(P＜0.05).〖WTHZ〗Conclusion〖HTSS〗Through the examination of blood transfusion medical records, the medical records of blood transfusion in the hospital were improved, however, there are still some problems, so the training of clinicians should be strengthened to further improve the quality of blood transfusion records.