Evaluation and analysis of quality of clinical transfusion medical records

Objective:To statistically analyze the existence of quality defects and problems in blood transfusion medical records in our hospital in recent year,discuss improving writing quality of the clinical blood transfusion record,and constantly improve and refine hospital management system of clinical blood transfusion,so as to improve the safety and saving of the clinical blood transfusion.Method:According to clinical blood transfusion standard of the hospital,ten aspects and 16points in writing quality problems of the clinical blood transfusion record in recent years were statistically analyzed.Result:After evaluation of the blood transfusion record,there were significant differences in the clinical blood transfusion record within five points:the number ofitems missing of applicationwas the total 15.6%of the medical records of the transfusion;the number ofblood type or quantity not standardized of applicationwas the total 21.3% of the medical records of the transfusion;the number oflack or absence approval of massive transfusionwas the total 24.1%of the medical records of the transfusion;the number ofno evaluation before blood transfusionwas the total 27.1% of the medical records of the transfusion;the number ofno evaluation of post-transfusionwas the total 29.4% of the medical records of the transfusion.Conclusion:To effectively improve writing quality of blood transfusion medical record,develop and improve the clinical rational of the clinical blood transfusion,and establish the effective medical evaluation system and management mode could regulate the scientific clinical blood transfusion,and really improve clinical blood transfusion safety and its clinical efficacy.