摘要
目的:通过督查输血病历质量,分析存在问题,规范临床用血。方法:随机抽查某院2018年-2019年共计861份输血病历。从输血前评估、输血前检查、输血医嘱、输血知情同意书、输血记录、输血疗效的评估6个方面进行回顾性分析和比较。结果:2019年的输血病历合理率比2018年显著增加,差异有统计学意义(P=0.0178);输血病历各检查项目不合理率对比可见,与2018年相比较,2019年输血前的评估不合理率显著增加,差异有统计学意义(P=0.0067);输血记录不合格率升高。输血后疗效评估的不合格率升高,差异无统计学意义(P=0.0761)。结论:分析输血病历中不合格的原因,提出建议,规范临床科学合理用血并提高输血病历质量。
Objective:To improve the quality of the transfusion record documentation by analyzing the current records.We also hope the data would provide valuable reference data to minimize potential medical incidents.Methods:A Retro-spective analysis with 6 preset parameters were conducted on a random sample pool of 861 blood transfusion patients in our hospital recorded from 2018 to 2019.The presets included pre-transfusion assessment,pre-transfusion tests,transfusion medical advice,physician transfusion record integrity informed consent for transfusion therapy,post-transfusion assessment.Results:Compared with 2018,the total pass rate of blood transfusion records in 2019 increased significantly,with.Statistically significant(P=0.0178).In 2018 and 2019,the unqualified rate of each examination item in the blood transfusion medical record was compared.Compared with 2018,the unqualified rate of the pre-transfusion assessment was significantly increased (P=0.0067).It’s statistically significant.The unqualified rate of blood transfusion records increased,without statistical significance(P=0.0888).The post-transfusion assessment was increased.There was no statistical significance(P=0.0761).Conclusion:To improve clinical record documentation,We analyzed the causes of the disqualification in the medical records of blood transfusion and put forward Suggestions to standardize the clinical,scientific and rational use of blood.
作者
李振兴
章宗武
张文燕
王晓楠
王文君
陈同庆
LI Zhen-xing;ZHANG Zong-wu;ZHANG Wen-yan(Anhui NO.2 Provincial People's Hospital,Hefei 230041,Anhui)
出处
《安徽卫生职业技术学院学报》
2021年第2期93-95,共3页
Journal of Anhui Health Vocational & Technical College
关键词
临床输血
输血病历
病历质量
clinical blood transfusion
transfusion medical records
the quality of medical record