关键词: 信息系统, 输血病历, 电子病历, 质量控制

Abstract: Objective To improve the level of blood transfusion records by evaluating the transfusion cases in the whole hospital through the transfusion case evaluation system and monitoring the transfusion cases through the medical record quality control system. Methods Medical records of blood transfusion were evaluated according to the Implementation Rules of Beijing Regional Hospital Management Assessment and Evaluation Standards (2009 Edition), Medical Records Writing Standards, Technical Standards for Blood Transfusion and other relevant requirements. A total of 21 790 clinical blood transfusion records from 2015 to 2020 were collected through the medical record quality control system, among which 5 515 were collected from non-surgical departments and 16 275(actual blood cases 4134) from surgical departments. Using blood transfusion evaluation system for each classification and summary of problem to register, by withholding statement that links to the performance, and real-time feedback and monthly bulletin of blood transfusion of the public, the common problems of blood transful- sion duration omissions, evaluation of unfinished after blood transfusion, informed consent problem such as lack of item, to prompt or mandatory restric through electronic medical record quality control system, baning apply for a blood transfusion and discharge process until meeting the requirements mentioned above. Results From 2015 to 2020, the qualified medical records showed an increasing trend year by year(P＜0.05).The qualified rate of blood transfusion medical records in non-surgical departments (96.33%) was higher than that in surgical departments (88.90%). After the intervention of medical record quality control system in 2020, there was a significant improvement as compared with the previous five years' records (P＜0.01). Conclusions The quality of clinical blood transfusion records can be improved effectively by monitoring the whole process of blood transfusion records through the information system.

Key words: information system, blood transfusion medical records, electronic medical records, quality control