贵州医科大学学报

2015, v.40;No.173(02) 210-211+214

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临床输血病历规范性调查
Investigation of Medical Record Standardization of Blood Transfusion

杨胜高;朱俊伟;崔冬冰;
YANG Shenggao;ZHU Junwei;CUI Dongbing;Medical Laboratory ,People's Hospital of Yuqing County;Guiyang Medical College;Laboratory Center of Tissue Engineering and Stem Cells,Guiyang Medical College;

摘要(Abstract):

目的:分析输血病历书写中存在的问题,促进临床输血规范化。方法:抽取635份住院输血病历,分析输血病例的科室及病历书写中存在的问题。结果:635分输血病历中,手术科室284份,问题病历123份;非手术科室351份,问题病历78份;主要问题包括输血记录单填写不完整(7.72%),输血申请单填写不完整(5.98%)等。结论:临床输血病历书写仍存在问题,应引起足够重视。
Objective: To investigate potential existing problems concerning medical records of blood transfusion,and therefore to promote the standardization of blood transfusion. Methods: A total of 635 copies of medical records of blood transfusion in hospital were selected,and the departments of blood transfusion and the existing problems about medical records writing were analyzed. Results: Of all the635 copies of medical records,284 copies belongs to surgical departments with 123 questionable records; 351 copies from non-surgical departments and 78 copies were questionable. Major problems were incomplete blood transfusion( 7. 72%),incomplete application for blood transfusion( 5. 98%).Conclusions: Existing problems in medical records writing should attract management concern.

关键词(KeyWords): 输血;病历;调查
blood transfusion;records;investigation

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作者(Author): 杨胜高;朱俊伟;崔冬冰;
YANG Shenggao;ZHU Junwei;CUI Dongbing;Medical Laboratory ,People's Hospital of Yuqing County;Guiyang Medical College;Laboratory Center of Tissue Engineering and Stem Cells,Guiyang Medical College;

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