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【Objective】 To determine the value of quality assessment system in supervising standard clinical blood use and improving the quality of clinical blood transfusion medical records. 【Methods】 The clinical blood transfusion records of Children′s Hospital, Zhejiang University School of Medical every quarter from January 2019 to December 2022 were selected and extracted for evaluation by 5% to 10% for the current season. These blood transfusion medical records were scored and graded A(≥90 points)/B(80-89 points)/C(<80 points)according to the Evaluation Table of Clinical Science Rational Use of Blood in Children′s Hospital of Zhejiang University, and the annual A rate was statistically analyzed. After summarizing the deduction points, a rectification plan was submitted to the medical department and publicized on the hospital network. 【Results】 A total of 1 975 blood transfusion medical records were analyzed from January 2019 to December 2022, including 343 in 2019 (17.37%), 517 in 2020 (26.18%), 556 in 2021 (28.15%) and 559 in 2022 (28.30%), with Grade A rates at 67.06%, 92.07%, 93.17% and 91.06%, respectively. According to Pearson Chi-square test, the Grade A rates of blood transfusion records in 2020, 2021 and 2022 were significantly higher than those in 2019 (P<0.000 1). In the assessment, the main reasons for deduction of points were missed pre-transfusion immunization tests and missed blood transfusion course records. From 2019 to 2022, the missed rates of pre-transfusion immunization tests were 22.68%, 6.47%, 1.26% and 2.49%, and the missed rates of blood transfusion course records were 32.21%, 10.59%, 5.57% and 6.61%, respectively. 【Conclusion】 The regular and reasonable assessment and publicity system of blood transfusion medical records is conducive to improving the quality of blood transfusion medical records, promoting rational blood use and ensuring the safety of blood use for children.
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Los sistemas de información en los servicios de salud han contribuido en los procesos de automatización de historiales clínicos, desempeñando un papel importante en la atención médica. El objetivo de esta revisión ha sido identificar la importancia de los sistemas de información para la automatización de historiales clínicos y las herramientas usadas para su implementación. Se revisaron artículos de revistas indexadas en base de datos bibligráficas como: IEEE Digital Library, ScienceDirect, Scielo, Google Scholar con la finalidad de tener una mejor clasificación de información que aportara al desarrollo del contenido estudiado. Se identificó que los sistemas de información mejoran la comunicación médico-paciente, aceleran procesos de atención médica, reducen costos y tiempo. Los sistemas de información son importantes para la automatización de historiales clínicas, garantizado mejoras en el proceso de atención al paciente en los establecimientos de salud(AU)
Information systems in health services have contributed to the automation of medical records, playing an important role in medical care. The objective of this review was to identify the importance of information systems for the automation of medical records and the tools used for their implementation. Articles from journals indexed in bibliographic databases such as: IEEE Digital Library, ScienceDirect, Scielo, Google Scholar have been reviewed in order to have a better classification of information that contributes to the improvement of our interest topic. It has been identified that these information systems increase doctor-patient communication, speed up medical care processes, reduce costs and time. Information systems are important for the automation of medical records, guaranteeing advances in the patient care process in health establishments(AU)
Assuntos
Humanos , Masculino , Feminino , Prontuários Médicos , Assistência Centrada no Paciente , Sistemas de Informação em Saúde , Sistemas de Informação em Saúde/normas , PeruRESUMO
Objective To identify the problems of medical record management standardization in clinical case management for the study of medical record quality and give some corresponding measures.Methods 3,000 medical records of patients in our hospital from January 2015 to December 2016 were collected and divided into control group (with 1,500 records from January 2015 to December 2015) and observation group (with 1,500 clinical medical records from January 2016 to December 2016).The control group adopted regular data management while the observation group employed standardized lean management.Medical record defects, rectification rate and the average scores of inpatient medical records between the two groups were compared and analyzed.Results The average score of inpatient medical records in observation group was significantly higher than that of the control group (t=13.672, P<0.05), while the defect degree and the modification rate of the medical records were significantly lower than those of the control group (P<0.05).Conclusion Standardized medical record management contributes to the improvement of the quality of medical records.