输血病案质量标准化评价分析  

Standardized Evaluation Analysis on the Quality of Blood Transfusion Medical Records

作　　者：周军[1] 姚文娟[1] 陈琪[1] 耿艳莉[1] 

机构地区：[1]湖北十堰市人民医院,十堰市442000

出　　处：《中国病案》2015年第7期27-30,共4页Chinese Medical Record

摘　　要：目的通过建立临床输血病案评价标准,促进病案质量持续改进。方法以《医疗机构临床用血管理办法》、《临床输血技术规范》及《病历书写基本规范》为依据,制定医院输血病案评价标准,并对住院病人输血病案进行评价分析。结果输血病案质量评价标准建立前后病案缺陷数从平均每份病案1.116降低到0.332,P<0.001,下降明显;甲级病案率从32%提高到92.2%,P<0.001,提升明显。结论通过建立临床输血病案评价标准,强化输血病案质量评价,提高了医护人员规范执行输血制度的自觉性和对输血病案规范书写重要性的认识,促进了病案质量持续改进。?Objectives To promote the continuous quality improvement of medical records through the establishment of evaluation standards of clinical blood transfusion medical records. Methods To establish evaluation standards of clinical blood transfusion medical records with the accordance of ＂Clinical Blood Usage Management Methods of Medical Institutions＂, ＂Technical Specifications of Clinical Blood Transfusion＂ and ＂Basic Writing Norms of Medical Records＂, then conduct analysis on the blood transfusion medical records of hospitalized patients. Results The average defects number of each case of medical records had decreases from 1. 116 to 0. 332 after the establishment of quality evaluation standards of clinical blood transfusion medical records （P〈0. 001）, the class A rate had increased from 32% to 92.2% （P〈0. 001）. Conclusions Through the establishment of quality evaluation standards of clinical blood transfusion medical records and the strengthen of quality evaluation, the consciousness of blood transfusion system among the medical staff was improved as well as the standardized writing of blood transfusion medical records, which would promote the continuous quality improvement of medical records.

关 键 词：输血病案 管理 质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]