关键词: 输血, 合理输血, 病历分析

Abstract: Objective〖HTSS〗To investigate the problems existing in hospital blood transfusion records, analyze the unreasonable factors, improve the quality of blood transfusion records, and provide guarantees for safe blood transfusion.
〖WTHZ〗Methods〖HTSS〗According to “Management of blood for clinical use in medical institutions” and “Technical specifications for clinical transfusion”, develop evaluation criteria for clinical blood transfusion records, 1 183 blood transfusion records were randomly selected from clinical departments with blood transfusion, pre-transfusion testing, informed consent, indication assessment, course record, management of transfusion process, adverse reaction report and return of large amount of transfusion were evaluated. 
〖WTHZ〗Results〖HTSS〗A total of 1 183 medical records were randomly examined, among which 203 were defective, accounting for 17.16%. From 2016 to 2018, unqualified medical records decreased significantly, and the difference was statistically significant(P＜0.05). In 2016, the examination items of blood transfusion defect medical records accounted for a large proportion, and the proportion of defect cases was also relatively high. With the in-depth examination of blood transfusion medical records, the unqualified items in defect medical records decreased year by year, and the proportion of defect cases gradually decreased, with statistically significant difference(P＜0.05). By 2018, the unqualified items mainly focus on the evaluation of indications for blood transfusion(3.96%). Among the sampled medical records, 537 were from non-surgical departments, among which 55 were defective, accounting for 10.24%. There were 646 medical records in surgical departments, including 148 defective medical records, accounting for 22.91%. There were statistically significant differences in the proportion of qualified medical records between surgical departments and non-surgical departments in 2016 and 2017(P＜0.05). 
〖WTHZ〗Conclusion〖HTSS〗Through the examination of blood transfusion medical records, the medical records of blood transfusion in the hospital were improved, however, there are still some problems, so the training of clinicians should be strengthened to further improve the quality of blood transfusion records.

Key words: Blood transfusion, Reasonable blood transfusion, Case analysis