中国社区医师
中國社區醫師
중국사구의사
Chinese Community Doctors
2014年
14期
162-163
,共2页
输血%病案质量%医疗%安全
輸血%病案質量%醫療%安全
수혈%병안질량%의료%안전
Blood transfusion%Medical record quality%Medical treatment%Safety
目的：为医院的质量管理和医疗安全提供参考。方法：制定输血病案专项检查标准，对91份输血病案进行质量分析。结果：病案合格率：病案首页54%，知情同意书54%，输血指征76%，病程记录52%，输血前检查项目98%，输血评估70%。结论：输血病案质量影响病案的内涵和医疗质量与安全，医院应当加强输血病案质量管理，确保医疗安全，避免医疗纠纷。
目的：為醫院的質量管理和醫療安全提供參攷。方法：製定輸血病案專項檢查標準，對91份輸血病案進行質量分析。結果：病案閤格率：病案首頁54%，知情同意書54%，輸血指徵76%，病程記錄52%，輸血前檢查項目98%，輸血評估70%。結論：輸血病案質量影響病案的內涵和醫療質量與安全，醫院應噹加彊輸血病案質量管理，確保醫療安全，避免醫療糾紛。
목적：위의원적질량관리화의료안전제공삼고。방법：제정수혈병안전항검사표준，대91빈수혈병안진행질량분석。결과：병안합격솔：병안수혈54%，지정동의서54%，수혈지정76%，병정기록52%，수혈전검사항목98%，수혈평고70%。결론：수혈병안질량영향병안적내함화의료질량여안전，의원응당가강수혈병안질량관리，학보의료안전，피면의료규분。
Objective:To provide reference for quality management of hospital and medical safety.Methods:Formulate blood transfusion medical record special inspection standard ,and then analyze the quality of 91 cases of blood transfusion medical record.Results:The qualified rate of the medical record:home page of medical record was 54% ,informed consent was 54% , transfusion trigger was 76% ,progress note was 52% ,inspection item before blood transfusion was 98% ,evaluation of blood transfusion was 70%.Conclusion:The blood transfusion medical record quality can influence the connotation of the medical record and quality and safety of medical treatment.Hospitals should strengthen the quality management of blood transfusion records,to ensure medical safety and avoid the medical dispute.
