结合PDCA循环建立可量化的输血病历评价体系  

To establish a quantifiable evaluation system in improving blood transfusion medical records based on PDCA

作　　者：李伟超 程道胜[1] 杜志和 LI Weichao;CHENG Daosheng;DU Zhihe(Department of Blood Transfusion,Jiangmen Central Hospital,Jiangmen 529010,China.)

机构地区：[1]江门市中心医院输血科,广东江门529010

出　　处：《中国输血杂志》2024年第2期203-208,共6页Chinese Journal of Blood Transfusion

摘　　要：目的探讨建立可量化的输血病历评价体系结合戴明环(Plan-Do-Check-Act,PDCA)循环对输血病历改进的可行性。方法本院建立输血病历评价小组,根据相关规范、文献建立输血病历评价体系,以2022年9月—2023年2月病历数据为对照组,以2023年4—5月为研究组,运用PDCA循环,分析病历质量差的原因,对输血病历质量进行为期2个月的改进,并对结果进行分析、整理。结果研究组与对照组对比,输血治疗同意书(A项)分数由原来的17.50±5.54分上升到21.08±3.75分(P<0.01);输血申请(B项)分数由原来16.22±2.05分上升到17.33±1.85分(P<0.01);输血评估(C项)分数由原来的13.05±3.5分上升到14.72±1.97分(P<0.01),输血严重危害(F项)分数由原来7.9±1.44分上升到8.7±0.92分(P<0.01),病历总分由原来的85.36±7.5分上升到93.05±5.04分(P<0.01)。病历合格率由原来的82.2%上升到98.3%(P<0.01)。结论建立可量化的输血病历评价体系结合PDCA循环可促进输血病历的及时性、规范化、标准化。Objective To explore the feasibility of establishing quantifiable evaluation system combined with PDCA in improving blood transfusion medical record.Methods A working group was set up in our hospital to establish an evaluation system for blood transfusion medical record according to relevant norms and literature.The data from September 2022 to February 2023 were used as the control group,and data from from April to May 2023 as the study group.PDCA was used to analyze the causes for poor quality of medical record.The quality of medical record was continuous improved for two months and the results were analyzed.Results Comparison between the research group and the control group showed that the score of blood transfusion consent(item A),blood transfusion application(item B),blood transfusion evaluation(item C),blood transfusion serious hazard(item F)increased respectively as 17.50±5.54 vs 21.08±3.75(P<0.01),16.22±2.05 vs 17.33±1.85(P<0.01),13.05±3.5 vs 14.72±1.97(P<0.01),7.9±1.44 vs 8.7±0.92(P<0.01),and the total score of medical record was 85.36±7.5 vs 93.05±5.04(P<0.01).The qualified rate of medical record increased from 82.2%to 98.3%(P<0.01).Conclusion The establishment of quantifiable blood transfusion medical record evaluation system combined with PDCA can help realize timely regulation and standardization of blood transfusion medical record.

关 键 词：评价体系 输血病历 PDCA 

分 类 号：R733.72[医药卫生—肿瘤] R457[医药卫生—临床医学]