奥马哈系统在社区慢性病健康档案记录中的应用  

Feasibility of Using Omaha System for Community-based Management of Electronic Health Records of Chronic Disease Patients

作　　者：朱雪娇 牛丹 蔡冰琳 ZHU Xue-jiao;NIU Dan;CAI Bing-lin(Nursing Department,School of Medicine,Hangzhou Normal University,Hangzhou 310036,China)

机构地区：[1]ZHU Xue-jiao

出　　处：《中国全科医学》2018年第9期1080-1084,共5页Chinese General Practice

基　　金：2018年浙江省医药卫生科技计划项目(2018KY146);2014年浙江省医药卫生科技计划项目(2014KYA165)

摘　　要：背景社区居民健康档案已逐步建成,但因记录系统和记录语言不统一,难以实现信息共享。目的分析奥马哈系统应用于现有社区慢性病患者健康档案记录的可行性。方法 2015年9月—2016年4月,采用便利抽样法选取杭州市某社区卫生服务中心辖区内的慢性病患者87例,研究员采用奥马哈系统入户评估社区慢性病患者的健康问题;同时对这些患者在社区卫生服务中心建立的健康档案记录进行回顾整理,然后依据奥马哈系统进行归类。对两种记录中发现的健康问题的症状/体征进行匹配。结果入户评估发现30个健康问题、146个症状/体征,健康档案记录发现19个健康问题、95个症状/体征。两种记录中症状/体征完全匹配35.8%(34/95),不完全匹配55.8%(53/95)。结论奥马哈系统记录与目前使用的健康档案记录在慢性病患者的健康问题及其症状、体征方面基本匹配,该系统可以被纳入现有的健康档案系统中,并有利于提供更多的患者健康相关信息。Background Although the information system of community residents'electronic health records(EHRs)has been established,the data can hardly be shared due to the recorded information is inconsistent with the told information.Objective To investigate the feasibility of using Omaha System for community-based management of the EHRs of chronic disease patients.Methods This study was conducted from September 2015 to April 2016.Using convenience sampling,we recruited the chronic disease patients(n=87)receiving the management of a community health service center(CHSC)in Hangzhou.Using the Omaha System,our researchers carried out a door-to-door survey for assessing the participants'health problems,and classified the health problems recorded in their EHRs kept in the CHSC after reviewing.The identified symptoms and signs recorded both in the survey and EHRs were compared.Results A total of 30 health problems with 146 symptoms/signs were found by door-to-door survey using the Omaha System while a total of 19 health problems with 95 symptoms/signs were found by reviewing the health records.In these two health records collected by different ways,35.8%(34/95)of the symptoms/signs were fully matched,and 55.8%(53/95)were partially matched.Conclusion The chronic disease patients'health problems as well as symptoms and signs recorded by using Omaha System are basically consistent with those previously recorded in the EHRs,so it can be used for the management of EHRs.Moreover,by using it,more detailed health data can be collected.

关 键 词：慢性病 电子健康病历 奥马哈系统 

分 类 号：R197.323[医药卫生—卫生事业管理]