河北省医疗机构临床用血病历调查与分析

Survey and Analysis of Medical Records of Clinical Blood Use in Medical Institutions in Hebei Province

目的 了解河北省医疗机构临床用血病历存在问题,为质量改进提供理论依据.方法 于2013年4月～ 2014年4月,在河北省11个地市范围内分别选取三级、二级、一级各10家医院各10份临床用血病历进行调查与分析.结果 临床用血病历9项指标中,三级医院合格率最高,一级及民办医院合格率最低.各项指标记录水平不均衡,尤以输血后疗效评价、输血不良反应回报单合格率最低.结论 相关管理部门应强力推行统一的病历记录标准,大力开展医务人员培训,加大督导检查力度等,以规范临床用血病历记录,提高临床科学合理用血水平.

Objective To investigate the problems in medical records of clinical blood use in medical institutions in Hebei Province to provide evidence for quality improvement.Method From April 2013 to April 2014,10 medical records of clinical blood use from each of the 10 hospitals which were included from each of the three levels hospitals in 11 regions in Hebei Province were investigated and analyzed.Result Among the 9 indicators of the medical records of chnical blood use,the thrid-level hospital had the highest passing rate,and the first-level and private hospital had the lowest pass rate.The indicators had uneven record level,and the efficacy evaluation after transfusion and the adverse events report of transfusion had the lowest passing rate.Conclusion The relevant authorities should implement unified medical records standards,vigorously carry out the training of medical personnel,and strengthen supervision and inspection efforts,in order to regulate medical records of clinical blood use and improve clinical scientific and rational use of blood.