临床输血病案质量分析与评价  

Quality Analysis and Evaluation of Clinical Blood Transfusion Records

作　　者：李红燕 汪艳菲 周家济 卢坤 徐志强 Li Hongyan;Wang Yanfei;Zhou Jaji;Lu Kun;Xu Zhiqiang(Huangshan People's Hospital,Huangshan 245000,Anhui Province,China;不详)

机构地区：[1]黄山市人民医院,安徽省黄山市245000

出　　处：《中国病案》2025年第2期3-6,共4页Chinese Medical Record

基　　金：黄山市人民医院科研课题(2024KJ-14)。

摘　　要：目的 分析输血病案中存在的问题,提出整改对策,提高临床输血病案质量。方法 采用《输血病历质量考评表》,对黄山市某医院2019年1月1日-2022年12月31日定期分科室随机抽查的临床输血病案进行回顾性分析和评价。结果 共抽查输血病案2560份,总体合格率为83.44%(2136/2560),2019年-2022年合格率呈逐年上升趋势。424份不合格输血病案中合理输血的不合格率最高,达49.29%(209/424),且2022年合理输血的不合格率显著高于前三年(P<0.05)。内、外科系统总体不合格率分别为6.77%(62/916)、22.02%(362/1644),2019年-2022年外科系统的输血病案不合格率均明显高于内科系统(P<0.001)。结论 通过定期检查输血病案规范性及完整性,输血病案整体质量有所提高,但部分内容缺陷仍未见明显改善,需持续改进和完善输血病案质量评价体系,加强输血病案管理。Objectives To analyze problems in blood transfusion medical records,put forward the corrective measures,and improve the quality of clinical blood transfusion medical records.Methods The clinical blood transfusion medical records were randomly checked by different departments from January 1st,2019 to December 31st,2022 in a hospital in Huangshan were retrospectively analyzed and evaluated by using"Quality Evaluation Table of Blood Transfusion Records".Results A total of 2560 blood transfusion records were consulted,with an overall qualification rate of 83.44%(2136/2560).The qualification rate has been increasing year by year from 2019 to 2022.The highest unqualified rate of reasonable blood transfusion among 424 unqualified blood transfusion records was 49.29%(209/424);And the unqualified rate of reasonable blood transfusion in 2022 was significantly higher than that in the previous three years(P<0.05).The overall unqualified rates of the internal and surgical systems were 6.77%(62/916)and 22.02%(362/1644),respectively.From 2019 to 2022,the unqualified rates of blood transfusion records in the surgical system were significantly higher than that in the internal medicine system(P<0.001).Conclusions Through regular inspection of the standardization and integrity of blood transfusion records,the overall quality of blood transfusion records had been improved,but some content defects had not been significantly improved.It was necessary to continuously improve and perfect the quality evaluation system of blood transfusion records and strengthen the management of blood transfusion records.

关 键 词：临床输血病案 质量评价 合理输血 

分 类 号：R457.1[医药卫生—治疗学]