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目的通过输血病历考评,促进某市科学、合理用血,节约血源。方法通过对2013年-2015年输血病历中输血适应症、输血申请、输血记录、输血疗效评价四大方面进行检查,其中输血适应症主要查看其合理性,输血申请、输血记录、输血疗效评价主要查看其相关文书记录是否规范、完整。分别对扣分病案次数、每月平均分及合格率进行分析。结果不合理用血占比2014年5.76%较2013年14.64%明显下降,2015年较2014年变化不明显,主要是血浆及冷沉淀的不合理输注,其中血浆由52.41%下降至27.59%,冷沉淀由24.24%下降至3.7%;输血申请、输血记录、输血疗效评价等相关文书记录扣分病案占比逐年下降。2014年每月考评平均分最高,2015年前6月平均分较低,后6月平均分接近2014年平均分,最后一月平均分较2014年高,高达94.75。每月合格率变化趋势与平均分相同,最后一个月合格率高达96.12%。结论由近3年考评结果可知:输血病案考评能促进合理用血,规范文书书写,推进病案质量持续改进,保障医疗安全。
Objective Through blood transfusion records evaluation, promote a city of science, rational use of blood, save blood. Methods According to the four aspects of transfusion indications, transfusion records, blood transfusion records and blood transfusion evaluation in transfusion records from 2013 to 2015, the main indications for transfusion admission were its rationality, application of blood transfusion, transfusion records and evaluation of main transfusion efficacy Check whether the records of related documents are standard and complete. Respectively, the number of points deducted medical records, monthly average score and pass rate analysis. The results showed that the proportion of unreasonable use of blood decreased significantly from 5.76% in 2014 to 14.64% in 2013, but not significantly changed from 2015 to 2014, mainly due to the unreasonable infusion of plasma and cryoprecipitate, in which plasma decreased from 52.41% to 27.59% Cold sedimentation decreased from 24.24% to 3.7%; blood transfusion records, blood transfusion records, blood transfusion evaluation and other related instruments recorded the proportion of points decreased year by year. In 2014, the monthly average score was the highest, with a lower average in June and June 2015, followed by an average of nearly the 2014 average in June and an average of 94.75 in the last month, compared with 2014. The monthly pass rate changes with the same average, the last month pass rate as high as 96.12%. Conclusion According to the assessment results of the past three years, the evaluation of transfusion cases can promote the rational use of blood, standardize the writing of instruments, promote the continuous improvement of the quality of medical records and ensure the medical safety.