目的 分析输血病案中存在的缺陷,规范和提高临床输血病历书写质量,防范临床用血医患纠纷.方法 检查某院2016年1月1日至2016年12月31日住院患者输血病案2268份,并对其中675份缺陷病案进行调查分析.结果 输血病案缺陷率为33.5%,主要项目缺陷分别为:输血知情同意书缺陷占8.7%、住院病案首页缺陷占12.4%、病程记录缺陷占16.2%、疗效评估缺陷27.8%、输血记录单缺陷占38.5%.结论 临床输血病案中存在诸多缺陷,需进一步强化医务人员法律意识,规范书写标准,确保输血流程的安全性和科学性.%Objective To analyze the defect problems existing in blood transfusion medical records and improve the quality of clinical blood transfusion medical records, in order to prevent medical tangle risk. Methods A total of 2268 blood transfusion medical records were collected on January1 to December 31,2016 of these records, of these, 675 defect records were analyzed. Results The defect rate of blood transfusion was 33.5% (675/2268). The main defect items rate of transfusion informed consent, home page, disease course, therapeutic efficiency evaluation, blood transfusion record was respectively 8.7%, 12.4%, 16.2%, 27.8%, 38.5. Conclusions So much defects were existing in the blood transfusion medical records, defect problems should not be ignored in general items, we need strengthen the law awareness of medical staff, standardize the writing criterion, in order to ensure the quality and scientificity of blood transfusion.
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