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《Chinese Medical Record》 2012-05
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Defects and Countermeasures of Medical Records of Transfusion in a Hospital

Han Fuwang,Department of Transfusion,Dongfang Hospital of Beijing Chinese Medicine University,Beijing 10078,China  
Objective This paper aims at strengthening management of documents regulations of medical records of transfusion,improving quality of medical records of transfusion and preventing medical tangle risk of clinical usage of blood.Methods According to Defects Examination Table of Medical Records of Transfusion formulated by Beijing Technical Regulations of Clinical Transfusion,Evaluation Detailed Rules and Regulations of Department of Transfusion(blood bank) in Beijing,314 medical records of transfusion were randomly examined according to items in the table from Jan 1 2011 to Dec 31 2011,which were separated into first half year and second half year for spot check.It is took that 100 points as full score;95 to 99 points as the average defects;below 95 points as severe defects and unqualified medical records.Results In these two spot check,100 points of medical records from 61.7% raised to 82% accounting up in total number in first half year;defects medical records from 38.3% decreased to 18 accounting up in total number in first half year;unqualified medical records from 15.5% decreased to 6.5% accounting up in total number.Conclusions Whether the quality of transfusion medical records is standard may directly affect connotation and medical quality and safety of medical records.Hospital should enhance quality management of transfusion medical records,making sure the medical safety and avoiding the occurrence of medical tangle.
【CateGory Index】: R197.3
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