Objective Through the examination of the blood transfusion medical records in a provincial public hospital, the influencing factors and countermeasures of the blood transfusion medical records were analyzed and discussed, and the quality of the blood transfusion medical records were improved. Methods Based on the theory of PDCA circulation theory, according to the relevant laws and regulations, A comparative study was conducted on the information quality of blood transfusion medical records in May, 2016 (control group) and August 2016 (observation group). Results The defect rate of the blood transfusion course record(5.05%), informed consent for blood transfusion(12.46%), blood transfusion record (2.02%), physician order(5.05%), the transfusion without indications(5.39%)and home page blood typing error (0%)of the observation group are significantly lower than those of the control group,the differences are significant (P<0.05). Conclusion PDCA circulation method makes blood transfusion quality management system perfect, management measures in place and the level of information improving constantly, and effectively improves the quality of transfusion medical records.%目的 通过对某三级综合医院输血病案质量进行检查,分析输血病案质量的影响因素,不断提升输血病案质量.方法 采用PDCA循环质量控制理论,依据相关法律、法规,以2016年5月实施PDCA循环前的250份输血病案做为对照组和2016年8月实施PDCA循环后的297份输血病案为观察组进行对比研究.结果 观察组在输血病程记录缺陷(5.05%)、输血知情同意书缺陷(12.46%)、输血记录单缺陷(2.02%)、医嘱不规范(5.05%)、无指征输血(5.39%)、病案首页血型填写错误(0%)方面的缺陷率均大幅度下降,明显低于对照组,差异具有统计学意义(P<0.05).结论 PDCA循环法应用于输血病案质量管理,使输血质量管理体系趋于完善,管理措施具体到位,信息化水平不断提高,有效地提高了输血病案质量.
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