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目的了解输血病案存在的质量缺陷,探讨提高病历质量的办法。方法随机抽取某院2012年出院病人的中2468份输血病案,并对716份存在缺陷的病历进行回顾性分析。结果在2468份输血病案中,输血病案总合格率71%。被抽查的缺陷病案中,病案首页、病程记录、手术记录单、麻醉记录单、输血同意书、输血记录单、输血不良反应回报单缺陷率分别为10.89%、3.35%、2.51%、3.63%、59.78%、45.39%、11.45%。结论从领导重视、强化医务人员的法律意识、加大对年轻医师的培训和考核力度、创建信息化质控管理平台等方面入手,促进病历质量持续改进,提高医院质量管理水平。
Objective To understand the quality defects of transfusion cases and to explore ways to improve the quality of medical records. Methods A total of 2468 cases of blood transfusion were randomly selected from discharged patients in a hospital in 2012 and 716 cases were analyzed retrospectively. Results In 2468 cases of blood transfusion, the total passing rate of transfusion cases was 71%. Among the defective medical examination cases, the single defect rate of the first page of the medical record, the record of the medical record, the surgical record sheet, the anesthesia record sheet, the consent form of blood transfusion, the transfusion record sheet and the transfusion adverse reaction report were 10.89%, 3.35%, 2.51% and 3.63% 59.78%, 45.39%, 11.45%. Conclusion From the perspectives of leaders, strengthening legal awareness of medical personnel, increasing training and assessment of young physicians and establishing information quality control management platform, we should continue to improve the quality of medical records and improve the quality of hospital management.