某三甲医院输血病历书写调查分析及对策

Investigation and Analysis of Blood Transfusion Medical Records in a Third-class Hospital and Its Countermeasure

目的通过对某三甲医院的输血病历进行检查与结果分析后,制定具有针对性的整改措施,从而促进病历书写的规范性。方法抽取本院2016 年1 月—2018 年5 月三个年度的病历,从输血知情同意书、输血前后评估、输血记录等方面进行评价,总结病历书写过程中存在的问题,并对其原因进行探究。结果知情同意书欠完整、知情同意书缺少医患双方或一方签字、缺少输血前评估、缺少输血过程记录、输血不良反应未记录、缺少输血后疗效评价是某院近三年来病历书写中存在的问题,且每项对比差异除一项外均具有统计学意义,缺陷率逐年减少。2016 年与2017 年比较,除输血前评估、输血后疗效评价外,其余项目差异均存在统计学意义(P < 0.05);2017 年与2018 年相比,除知情同意书医患双方签名外,其余项目差异均存在统计学意义(P< 0.05)。结论针对存在问题要及时采取有效整改措施,并进行规范管理,这样才可避免输血病历书写缺陷情况的发生。

Objective To formulate pertinent rectification measures after examining and analyzing the blood transfusion medical records of a thirdclass hospital, so as to promote the standardization of medical records writing. Methods The medical records of our hospital from January 2016 to May 2018 were collected and evaluated from the aspects of informed consent of blood transfusion, pre-and post-transfusion evaluation and transfusion records. The problems in the process of writing medical records were summarized and the causes were explored. Results Informed consent is incomplete, informed consent is lacking signing by both doctors and patients, lack of pre-transfusion assessment, lack of blood transfusion process records, untranslated adverse reactions of blood transfusion, lack of transfusion after evaluation of efficacy is a problem in the writing of medical records in a hospital in the past three years And each comparison difference is statistically significant except one item, and the defect rate decreases year by year. In 2016, compared with 2017, except for pretransfusion assessment and post-transfusion efficacy evaluation, the differences of other items were statistically significant (P < 0.05). In 2017, compared with 2018, except for the signature of both doctors and patients. The remaining items were statistically significant (P < 0.05). Conclusion In order to solve problems, it is necessary to take effective corrective measures in a timely manner and conduct standardized management so as to avoid the occurrence of defects in blood transfusion records.