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输血是抢救生命、治疗疾病的重要医疗手段之一,但输血是一把双刃剑,在治疗患者的同时,也给患者带来巨大的风险。输血病历是治疗、抢救患者过程最原始的文字记录,是一份客观的法律文书。一份完整合格的病历不仅体现了医护人员的责任心,也可减少不必要的医疗纠纷。近年来,有多家医院报道了临床输血病历文书的书写情况[1],我院作为肝病专科医院,有自身特点。为了加强我院临床输血病历的管理,发现质量漏洞,现对我院2012年4 125份输血病历进行回顾性检查分析,报告如下。材料与方法1.资料来源:在我院临床输血信息管理系统、医生工作站中调查2012年1月1日至12月31日的
Blood transfusion is one of the important medical treatments for saving lives and treating diseases. However, transfusion is a double-edged sword, which brings great risks to patients while treating patients. Transfusion medical records is the treatment of the most primitive records of patients with the process of saving records, is an objective legal instrument. A fully qualified medical record not only reflects the medical staff’s sense of responsibility, but also reduce unnecessary medical disputes. In recent years, a number of hospitals reported the clinical transfusion records of writing instruments [1], our hospital as a liver disease hospital, has its own characteristics. In order to strengthen the management of clinical transfusion records in our hospital and to find loopholes in quality, we retrospectively reviewed 4,125 blood transfusion records in our hospital in 2012, and the report is as follows. Materials and methods 1. Source: In our hospital clinical blood transfusion information management system, the doctor workstation to investigate the January 1, 2012 to December 31 of