农村乡县跨级住院患者就诊信息传递现状分析  

Research on Analysis of Current Situation of Treatment Information Transfer of Township-county Readmission

作　　者：卢珊[1,2] 张亮[1,2] 唐文熙[3] 张研[1,2] 

机构地区：[1]华中科技大学同济医学院医药卫生管理学院,湖北武汉430030 [2]湖北省人文社科重点研究基地农村健康服务研究中心,湖北武汉430030 [3]中国药科大学国际医药商学院,江苏南京211198

出　　处：《中国医院管理》2016年第4期15-17,共3页Chinese Hospital Management

基　　金：国家自然科学基金资助项目(71273099);中国博士后科学基金面上项目(2015M582231)

摘　　要：目的了解目前我国农村地区跨级住院患者县级住院时乡镇就诊信息传递现状及问题。方法通过对我国东、中、西部5个县区新农合数据库清理匹配,筛选出两系统疾病乡县跨级住院病历439套,由临床专家针对病历就信息传递相关问题进行评判。结果乡县跨级住院患者中1/4不会反映前次就诊经历,专家认为68.2%的前次就诊信息对后续诊疗有贡献。自询诊患者比转诊患者反映前次就诊经历的比例更高,随着再入院时间间隔的延长,患者传递信息比例下降。患者向县级医生反映前次就诊机构和治疗方式的比例较高,较少提及诊断结果和曾用药。患者传递信息的概率是71.3%,其中有效的传递量为49.5%。结论患者反映前次就诊信息的意识差,再入院时信息传递内容缺失严重,跨级住院特征中再入院方式和住院时间间隔对信息传递的影响较大。Objective To figure out the status of inpatient treatment information transfer during readmission between township hospitals and county hospitals in rural China. Methods Firstly,we chose diseases of respiratory system and cerebrovascular system as the targets disease. To get the multi-institutional readmission information, we screened the databases of the New Rural Cooperative Medical System（NCMS） in 5 counties distributed in eastern,middle and western China. According to the results of screening,we finally got 439 sets of medical records in township hospitals and county hospitals. Lastly,2 medical specialists evaluated the medical records on information transfer. Results A quarter of readmission patients did not mention their experience before the readmission. In the views of the specialists,68.2% of the information mentioned by patients was useful. Patients by referral were more unlikely to transfer information than others. The longer the time interval before readmission,the less the information transfer. Patients were more likely to mention the hospitals and the treatments their accepted,while they seldom told doctors the diagnosis and the drugs they had taken. 71.3% of the patients had transferred treatment information and49.5% of the information was helpful. Conclusion Patients lacked of conscious awareness of information transfer. The information mentioned by patients during readmission was incomplete. The pattern and time interval of readmission had greater impact on information transfer.

关 键 词：再入院 跨级住院 信息传递 

分 类 号：R197.3[医药卫生—卫生事业管理]