摘要
目的降低由于病历书写不规范导致的医疗纠纷风险。方法选取南宁市用血量较大的4家医院的临床用血病历进行抽样调查。内容包括备/输血医嘱及输血治疗同意书、输血前相关检查、配血及发血记录、病程记录与护理记录4个方面。结果 4家医院抽查用血病历共计336份。分析发现病程记录与护理记录缺陷较严重,其它3项的缺陷率在不同医院有所不同。结论相关部门应加强临床输血病历的规范化管理,以降低医疗纠纷风险。
Objective To reduce transfusion medical disputes caused by non - standard medical writing. Method Four hospitals with big blood usage in Nanning city were selected to enter the survey with randomized clinical medical records. The survey included four aspects： prepared / blood transfusion treatment of doctor＇s advice and consent, relevant examinations before blood transfusion, blood match and blood allocation records, and process records and nursing records. Result A total of 336 blood medical records from four hospitals were analyzed. The process records and nursing records were found serious deficiencies, the other three aspects also had different defect rate in different hospitals. Conclusion The relevant departments should strengthen the standardization of medical records for clinical blood transfusion management in order to reduce the risk of blood transfusion medical dispute.
出处
《中国卫生质量管理》
2010年第2期88-90,共3页
Chinese Health Quality Management
关键词
临床
输血病历
规范性
调查
Clinic
Transfusion Records
Normative
Investigation
