病历质控系统在输血病历中的应用  

Application of medical record quality control system in blood transfusion records

作　　者：于永敬[1] 汤毅楠 张媛[1] 陈燕[1] 李小飞 YU Yong-jing;TANG Yi-nan;ZHANG Yuan;CHEN Yan;LI Xiao-fei(Department of Blood Transfusion, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China)

机构地区：[1]首都医科大学附属北京友谊医院输血科,北京100050

出　　处：《基础医学与临床》2021年第10期1554-1558,共5页Basic and Clinical Medicine

基　　金：北京市医院管理中心消化内科学科协同发展中心专项经费(XXX0108)。

摘　　要：目的通过输血病历评价系统评价全院输血病例,并通过病历质量控制系统监控输血病例,以期全面改进输血病历水平。方法根据《北京地区医院管理考核评价标准实施细则(2009版)》《病历书写规范》《输血技术规范》等相关要求,对输血病历进行评价。通过病历质控系统调取2015—2020年共21790份临床输血病历,其中非手术科室5515份,手术科室16275份(实际用血病历4134份)。采用输血评价系统对每一份病历问题进行登记分类和汇总,通过扣分制与绩效相关联,同时实时反馈并发布《输血月报》公示,对出现的共性问题输血病程遗漏、输血后评价未完成、知情同意书缺项等问题,通过电子病历质控系统进行提示或强制限制,未完成者禁止再次申请用血和禁止出院结算等方式,彻底对输血病历进行了全面全流程的监管。结果2015—2020年合格病历呈逐年上升趋势,每年较前一年增加(P<0.05)。非手术科室的输血病历合格率(96.33%)高于手术科室(88.90%),2020年病历质控系统干预后比前5年有大幅进步(P<0.01)。结论通过信息系统对输血病历进行全流程的监管,临床输血病历质量得到有效地提高。Objective To improve the level of blood transfusion records by evaluating the transfusion cases in the whole hospital through the transfusion case evaluation system and monitoring the transfusion cases through the medical record quality control system.Methods Medical records of blood transfusion were evaluated according to the Implementation Rules of Beijing Regional Hospital Management Assessment and Evaluation Standards(2009 Edition),Medical Records Writing Standards,Technical Standards for Blood Transfusion and other relevant requirements.A total of 21790 clinical blood transfusion records from 2015 to 2020 were collected through the medical record quality control system,among which 5515 were collected from non-surgical departments and 16275(actual blood cases 4134)from surgical departments.Using blood transfusion evaluation system for each classification and summary of problem to register,by withholding statement that links to the performance,and real-time feedback and monthly bulletin of blood transfusion of the public,the common problems of blood transful-sion duration omissions,evaluation of unfinished after blood transfusion,informed consent problem such as lack of item,to prompt or mandatory restric through electronic medical record quality control system,baning apply for a blood transfusion and discharge process until meeting the requirements mentioned above.Results From 2015 to 2020,the qualified medical records showed an increasing trend year by year(P<0.05).The qualified rate of blood transfusion medical records in non-surgical departments(96.33%)was higher than that in surgical departments(88.90%).After the intervention of medical record quality control system in 2020,there was a significant improvement as compared with the previous five years'records(P<0.01).Conclusions The quality of clinical blood transfusion records can be improved effectively by monitoring the whole process of blood transfusion records through the information system.

关 键 词：信息系统 输血病历 电子病历 质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]