胃肠肿瘤围手术期输血记录监控结果分析

Analysis of Monitoring Results for Perioperative Blood Transfusion in Medical Records of Gastrointestinal Tumor Cases

目的分析胃肠肿瘤围手术期输血记录的现状,探寻改进输血医疗文书质量的措施。方法临床用血管理委员会对2012年8月-2013年7月间143例胃肠肿瘤围手术期输血患者的病案开展院内检查,并对监控结果进行分析。结果在输血治疗过程中多个环节的记录存在缺陷,出院记录不合格率最高,为67.83%;其次是相关护理记录,不合格率为17.48%;输血记录单不合格率最低,为2.10%。结论输血记录是胃肠肿瘤围手术期病案中必有的内容,记录的质量对医疗纠纷的处理结果有一定的影响,需引起医疗工作人员的高度重视。

Objective To analyzing the current situation of peri-operation blood transfusion in medical record of gastrointestinal tumor cases, and put forward countermeasures and suggestions for improving quality of blood transfusion medical records. Methods The management committee of the blood clinical utilization carries out the inspection of the medical record, and analyzes the monitoring results of medical records of 143 gastrointestinal cancer cases with peri-operative blood transfusion from August 2012 to July 2013. Results Analysis results show that, there are some recording defects in the several aspects of blood transfusion treatment process. The failure rate of discharge records is the highest and the figure is 67.83%. Next is the transfusion related nursing records and its failure rate is 17.48%. The lowest failure rate is the blood transfusion records and the figure is 2.10%. Conclusions Peri-operative blood transfusion record is common in the medical records of gastrointestinal tumor cases, besides, it has certain legal effect for transfusion medical disputes and needs drawing great attention of medical staff.