高血压、糖尿病慢性病档案利用及中医药健康服务现况研究  

Current status of archives utilization of chronic diseases of hypertension and diabetes and health services of traditional Chinese medicine

作　　者：吕琳[1] 夏艾抒 尹芳[1] 刘豆[1] 周维维[1] Lv Lin;Xia Aishu;Yin Fang;Liu Dou;Zhou Weiwei(The Second Affiliated Hospital of Kunming Medical University,650101;The Third People's Hospital of Yunnan Province,650011)

机构地区：[1]昆明医科大学第二附属医院,650101 [2]云南省第三人民医院,1650011

出　　处：《中国社区医师》2017年第28期154-156,共3页Chinese Community Doctors

基　　金：昆明医科大学研究生创新基金(2015S96)~~

摘　　要：目的:探讨高血压、糖尿病慢性病档案利用及中医药健康服务现况。方法:抽取高血压和糖尿病患者慢性病档案782份,对40名医务人员和80名慢性病患者行问卷调查及访谈。结果:(1)所调查的慢性病患者健康档案未见接诊记录(86.7%)和转诊记录(98.59%),同一患者多次随访记录的数据和笔迹相同(23.02%)。(2)档案利用以随访动态记录率最高(92.33%),动态健康体检记录率次之(53.45%),档案缺漏项明显,随访记录漏项62.92%,体检辅助检查和中医体质辨识缺项漏项各为38.62%和32.99%。(3)医务人员对慢性病健康档案的重要性认识基本到位。(4)医务人员接受过档案管理相关培训,能及时记录和更新档案(均为82.5%);利用健康体检建立档案80.6%,档案用于患者体检、随访和健康教育分别占82.50%、77.50%和67.50%,用于社区门诊22.50%,用于双向转诊7.50%。(5)社区卫生服务机构管理激励与医务人员对档案利用的影响进行比较,差异有统计学意义(P<0.05)。(6)对患者认可慢性病档案与其建档意愿的比较,差异有统计学意义(P<0.05)。(7)4家机构中医药诊疗硬件设置健全,开展中医药健康服务总体情况良好。结论:所调查的高血压、糖尿病患者档案有不同程度利用,但用于双向转诊比例较低;档案质量管理欠规范,对档案利用造成直接影响;社区医务人员对慢性病档案管理认知较好,但缺乏有效的激励机制影响其积极性;慢性病患者对健康档案认知不足,建档意愿较低,影响了信任度;社区开展慢性病中医药健康服务总体良好,应加强培训,提高服务能力,突出服务优势,提高患者信任和依从性。Objective:To explore the current status of archives utilization of chronic diseases of hypertension and diabetes andhealth services of traditional Chinese medicine.Methods:782copies of chronic diseases of hypertension and diabetes wereselected for current utilization study.We conducted questionnaires and interviews with40cases of medical staff and80cases ofchronic patients.Results:①There were no records of medical records(86.7%)and referral records(98.59%)in health records forpatients with chronic diseases.In the same patient,the data and handwriting for repeated follow-up records were the same(23.02%).②In archival use,the follow up dynamic recording rate was highest(92.33%);the recording rate of dynamic physical examinationwas the second(53.45%);file missing item was obvious;the omission rate of follow-up records was62.92%;the rate of missingitems of physical examination and TCM constitution identification was38.62%and32.99%respectively.③Medical staff'sunderstanding of the importance of chronic disease health records was basically in place.④Medical personnel had been trained infile management,and can record and update files in time(all82.5%),set up files with physical examination(80.6%).The files wereused for physical examination,follow-up and health education of82.50%,77.50%and67.50%respectively,community clinic of22.50%,two-way referral of7.50%.⑤In the community health service organizations,the impact of management incentives andmedical personnel on the utilization of archives was statistically significant(P<0.05).?There were significant differencesbetween the patients who accepted the chronic disease archives and their willingness to make records(P<0.05).⑦In the4institutions,the hardware setup of the TCM diagnosis and treatment was sound,and the overall situation of carrying out the Chinesemedicine health service was good.Conclusion:The files of chronic diseases of hypertension and diabetes were used in varyingdegrees,but the ratio for two-way referral was lower.The quality management of archives

关 键 词：中医药 慢性病管理 健康档案 

分 类 号：R259[医药卫生—中西医结合]