摘要
目的探讨规范的输血病历书写及其相应的管理措施;方法分析输血病案中存在的缺陷及原因;结果输血病案质量在完整性和规范性等方面存在缺陷,这同医务人员对病案质量重视不够及医院病案质量管理监管力度不到位有关;结论加强对医师的法律培训和病历书写培训,加大病案质量控制,制定相应的病历书写规范可以提高输血病案的质量。
Objective To discuss the standard of blood transfusion medical records and management measures.Methods Analyzing defects and reasons of blood transfusion medical records.Results Defects appeared in the completeness and standardization of blood transfusion medical records which associated with less attention and inadequate supervision.Conclusion Intensify the legal awareness,strengthen quality control and establish the standard of blood transfusion medical records could improve writing quality.
出处
《中国病案》
2011年第8期20-21,共2页
Chinese Medical Record
关键词
输血病案
缺陷
质量控制
Blood transfusion medical records
Defect
Quality control
