20个社区居民健康档案建立及管理调查分析  

Investigation and analysis of establishment and management of resident health records in 20 communities

作　　者：周琰[1] 

机构地区：[1]十堰市太和医院户籍室,湖北十堰442000

出　　处：《西南国防医药》2016年第10期1222-1224,共3页Medical Journal of National Defending Forces in Southwest China

摘　　要：目的 调查分析社区居民健康档案建立管理现状,为有效提高健康档案利用率、更新完善健康档案提供依据.方法 随机分层抽样法抽取十堰市社区卫生服务机构20个,系统抽样法随机抽取1500份家庭、3000份个人纸质健康档案;另外依据健康档案编号,抽取各机构门诊登记健康档案居民各50名,共1000名,发放自行设计问卷调查表,调查内容包括居民基本信息、健康档案相关知识、利用率、利用内容、记录形式、疾病诊断等.结果 纸质家庭健康档案1年内利用率58.7％,个人健康档案利用率40.0％,门诊利用率41.6％.纸质个人健康档案、门诊健康档案使用中以门诊记录为主,分别占58.2％、69.3％.随着年龄的增加,门诊纸质健康档案利用率也随之升高（P＜0.05）;慢性疾病患者健康档案利用率50.8％,显著高于其他疾病患者的27.9％（P＜ 0.05）.门诊电子健康档案中,主诉、诊治记录完整占55.9％.41～70岁、大专及以上居民健康档案相关知识评分明显高于其他年龄段或文化程度段（P＜0.05）.结论 本地部分社区居民家庭档案利用率50％以上,个人健康档案利用率较低,可能与社区居民健康档案知识认知度低有关;门诊健康档案重视慢性疾病管理;电子档案记录完整率低,需进一步加强管理.Objective To investigate and analyze the establishment and management status of the health records of the residents in the communities, so as to provide the basis for improving the utilization rate of health records, and updating and completing health records. Methods A total of 20 community health service institutions in Shiyan City were selected by use of random stratified sampling method. The paper health records of 3,000 persons from 1,500 households were selected by use of systematic sampling method. In addition, a total of 1,000 records were selected according to the number of health records from different outpatient institutions, and 50 residents from each institutions. The self-designed questionnaires were issued. The contents of investigation included the basic information of the residents, the knowledge about health records, the utilization rate, the contents utilized, the form of records and the disease diagnosis. Results The utilization rate of papery household health records in one year was 58.7%. The utilization rate of personal health records was 40.0%, and that of outpatient records was 41.6%. The proportions of utilized papery personal health records and outpatient health records, in which the utilization of outpatient records was the main part, were 58.2% and 69.3% respectively. With the increase of age, the utilization rate of papery outpatient health records increased （P 〈 0.05）; the utilization rate of records of chronic diseases （50.8%） was significantly higher than those of other diseases （27.9%）（P 〈 0.05）. In electronic outpatient health records, complete records of complaints, diagnosis and treatment accounted for 55.9%. The scores of knowledge about papery outpatient health records in residents of 41-70 years old and whose educational level was higher than junior college were significantly higher than those in residents of other age or educational level （P 〈 0.05）. Conclusion The utilization rate of residents＇ household records in some communities is higher th

关 键 词：社区居民 健康档案 管理现状 认知度 

分 类 号：R195[医药卫生—卫生统计学]