某省县级结核病防治门诊病案质量调查与分析  

Investigation of Medical Record Quality in County Level Tuberculosis Control Clinics in One Province

作　　者：陈丹声[1] 陈求扬[1] 林淑芳[1] 林勇明[1] 

机构地区：[1]福建省疾病预防控制中心,福建福州350001

出　　处：《中国卫生质量管理》2011年第6期44-45,共2页Chinese Health Quality Management

摘　　要：目的了解福建省县级结核病防治门诊病案质量现状,为制定政策提供参考依据。方法随机抽查县级结核病防治门诊登记满1年的活动性肺结核患者病案资料,根据统一设计的表格进行检查。结果 5年间,大多数活动性肺结核病患者的病案资料已按要求及时整理归档;抽查的病案资料中,肝功能检查报告单、X线检查报告单、治疗协议书、治疗管理反馈单与服药督导卡等单据收集较完整,但痰涂片检查报告单的收集还有待改进;大多数病案记录相对简单。结论福建省县级活动性肺结核病患者病案资料质量逐步提高;应提高结核病防治门诊医生质量意识,加强病案资料的收集;必须强化结核病防治门诊医生自我保护的意识,规范书写病案。Objective To investigate medical record quality in county level tuberculosis （TB） clinics in Fujian, to provide reference for the formulation of policy. Method Through a random check of medical record information in county level TB clinic for one year registration of active TB patients, the unified design of table was investigated. Result During the five years, the majority of medical record for patients with active TB had been tidied up timely on request. Among the medical record, some documents were weft collected, including report of liver function tests, X - ray examination report, treatment agreement, treatment and management feedback, medication treatment supervision card. However, the collection of sputum smear examination report had to be improved; and most of the medical records were relatively simple. Conclusion The quality of county level medical records for active TB patients gradually improved in Fujian province. The quality awareness should be improved and medical record data collection and writing should be strengthened among out - patient doctors; and the medical self - protection awareness must be strengthened to standardize written medical record.

关 键 词：结核病控制 门诊 病案资料 质量 

分 类 号：R181.3[医药卫生—流行病学]