糖尿病临床诊治存在的问题——766例住院病案分析  

On the Current Conditions of the Clinical Practices for Diabetics-an Analysis on 766 Cases

作　　者：顾经宇[1] 唐伟[1] 武晓泓[1] 刘超[1] 

机构地区：[1]南京医科大学第一附属医院内分泌科,南京市210029

出　　处：《中国病案》2008年第4期44-47,共4页Chinese Medical Record

摘　　要：目的调查糖尿病临床诊治工作存在的问题,为改进和提高糖尿病诊治质量提供依据。方法提取2006年度内分泌科糖尿病住院病案,分析病案信息。结果首次住院766份病案中,仅对13.4%的患者检测了腰围。接受眼、颈部血管、神经等慢性并发症筛查的患者比例明显不足。缺乏对患者饮食、运动、接受糖尿病教育以及自我血糖监测的问诊。缺乏对患者心理和生活质量的问诊以及抑郁评分和诊断。结论临床医师对糖尿病患者问诊和体检的细致性、慢性并发症筛查工作以及病案质量等方面均有待加强。Objectives To survey the current clinical practices for diabetics.Methods All the data of the diabetics in the endocrine inpatient department of our hospital in 2006 were collected and analyzed.Results there are 766 records of the inpatients suffering diabetic,who were admitted first time,in the inpatient department in 2006.Only 13.4% of the waistlines of the patients had been measured.And only a few patients have received the screening test for their chronic complications.There is lack of the enquiries of the diet,exercise,self-management,the score of the psychology and the quality of life in all medical records,and no case had been diagnosed with depression.Conclusion The clinicians should enhance their clinical practices in enquiries,physical examinations,and screening test for the chronic complications.

关 键 词：糖尿病 并发症 临床病案信息管理系统 

分 类 号：R587.1[医药卫生—内分泌] R197.323[医药卫生—内科学]