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目的分析胃肠肿瘤围手术期输血记录的现状,探寻改进输血医疗文书质量的措施。方法临床用血管理委员会对2012年8月-2013年7月间143例胃肠肿瘤围手术期输血患者的病案开展院内检查,并对监控结果进行分析。结果在输血治疗过程中多个环节的记录存在缺陷,出院记录不合格率最高,为67.83%;其次是相关护理记录,不合格率为17.48%;输血记录单不合格率最低,为2.10%。结论输血记录是胃肠肿瘤围手术期病案中必有的内容,记录的质量对医疗纠纷的处理结果有一定的影响,需引起医疗工作人员的高度重视。
Objective To analyze the status of perioperative transfusion records of gastrointestinal tumors and explore measures to improve the quality of transfusion medical documents. Methods The clinical management committee conducted an in-hospital examination of 143 patients with transabdominal gastrointestinal tumors during August 2012-July 2013, and analyzed the surveillance results. Results There were defects in many aspects of transfusion during treatment. The highest failure rate was 67.83%. Followed by nursing records, the failure rate was 17.48%. The lowest transfusion record was 2.10%. Conclusion Blood transfusion records are necessary in the perioperative medical records of gastrointestinal tumors. The quality of the records has a certain impact on the treatment results of medical disputes and needs to be paid great attention to by medical staffs.