临床输血病历质量精准评估与分析

Accurate assessment and analysis of medical cases on blood transfusion

目的通过规范严格的输血病例管理,提高病历书写质量,为临床输血安全提供保障。方法制订输血病历检查量化评分标准,对1 009份临床输血输血病历进行评估分析。结果 2014年1月至2015年6月1 009份临床输血病史中缺陷病历数为179份(占17.7%)。随着每季度检查深入,总缺陷病历、一级缺陷病历与二级缺陷病历出现率逐渐下降,直至2015年第二季度分别降至14.2%、2.1%、1.6%(P<0.05)。然而,三级缺陷病历出现率下降不明显(P>0.05)。临床输血病历的病程记录输血指征不合理35份(占19.6%),无输注过程情况描述23份(占12.8),无临床症状描述或输血后疗效评17份(占9.5%)。结论临床输血病历检查与督导以及培训相关人员是提高输血病历质量,保障输血安全的有效手段。

Objective To improve the quality of medical case through strict case management of blood transfusion and to provide additional security for transfusion.Methods 1 009 transfusion cases were attached to this study and a scoring sys- tem was constructed to quantify them. Results Between January 2014 and June 2015, 179 defective eases were reported （account for 17.7%）. Then, quarterly supervision and inspection and overall defective cases were strengthened; defective eases of level 1 and 2 were decreased. So in the second .quarter of 2015, overall defeetive cases, defective cases of level 1 and 2 only accounted for 14. 2%, 2. 1%, 1.6% （P〈0. 05）. However, it had no significantly change on the prevalence of cases of level 3 （ P〉0. 05）. There were 35 cases （ which accounted for 19. 6% ）. The transfusion indications of which were not reasonable. There were 23 cases （which accounted for 12. 8%）, and of which, the descriptions of blood transfusion were blank. There were 17 cases （ which accounted for 9. 5% ）, of which, clinical symptoms and evaluation of transfusion were ab- sent. Conclusion Supervision and inspection are valid methods to provide security for transfusion and improve the quality of blood transfusion cases.