对临床输血病案文书质量的调查与分析

目的探讨临床输血病案文书的内涵质量。方法采取随机抽查的方法对某院2009--2010年已经归档的输血病案，按卫生部“医院管理年和医疗质量万里行”活动内容进行调查。结果发现多份病历不合格。结论临床输血病案文书是临床医师对患者治疗过程的原始记录，是当时事态的真迹，是医疗事故或纠纷在认定是非、判明责任，以及医疗技术鉴定或司法鉴定时赖以立论的依据。因此，写好病案文书可减少医疗纠纷的发生。

Investigation and Analysis of the Quality of Clinical Transfusion Medical Record Management

Objective To investigate the connotation quality of transfusion medical record documents. Methods A random spot-checks of blood transfusion has been discharged from hospital medical records from 2009 to 2010, according to ＂hospital management and medical quality improvement＂ published by the Ministry of Public Health. Results Multiple copies of medical records are failed. Conclusion Clinical transfusion medical record is the clinicians original record of the patient treatment process. It is the authentic performance of the teatment, and the basis of medical malpractice disputes, of responsibility identification, of medical techonology appraisal and of forensic identification. Therefore, the written medical record instruments can reduce the incidence of medical malpractice.