健康教育处方在门诊电子病历系统信息化开发及临床应用  

Development and application of outpatient medical record system-based electronic prescription on health education for outpatients

作　　者：胡小素[1] 胡何晶 张文丽[1] 王欣[1] 夏宇曦[1] HU Xiao-su;HU He-jing;ZHANG Wen-li(Department of Disease Control and Prevention,Peking University Third Hospital,Beijing 100191,China)

机构地区：[1]北京大学第三医院疾病预防控制处,北京100191

出　　处：《中国公共卫生》2021年第2期315-318,共4页Chinese Journal of Public Health

基　　金：北京市海淀区预防医学会科研课题(2018HDPMA04)。

摘　　要：目的探讨健康教育处方在门诊电子病历系统信息化开发及临床应用情况。方法采用定组研究方法抽取北京某三甲医院2265名门诊就诊患者开展电子健康教育处方应用前后问卷调查。结果在应用门诊电子健康教育处方中,观察组口头+书面健康教育措施的应用比例高于对照组(P<0.01);在医生除药物指导外对自己疾病有无针对性健康指导中,观察组在饮食、生活方式、心理健康、疾病机制讲解、额外健康指导比例均高于对照组(P<0.01);在应用电子健康教育处方对健康信念行为改变中,观察组在戒烟、减盐、限油、口腔健康、心理健康、合理用药、加强疾病自我管理比例均高于对照组(P<0.01);在应用电子健康教育处方获取健康宣教信息及医学素养提升中,观察组在接触健康宣教信息和医学素养提升比例均高于对照组(P<0.01)。结论信息化健康教育处方在门诊电子病历系统临床应用效果显著;其内容丰富,有精准、个性化健康指导,对改变患者健康信念、行为及获取医学信息和素养有很大帮助。Objective To explore the development and preliminary application of an electronic prescription on health education for outpatients.Methods We carried out a panel study in a tertiary hospital in Beijing from December 2019 through August 2010.First,we compiled electronic disease-specific health education prescriptions and implanted those prescriptions into an outpatient medical record system of the hospital.Then,we conducted questionnaire surveys among1163 outpatients as the control group before the implantation of the prescriptions and 1096 outpatients as the observation group after the implantation of the prescriptions.Results The proportions of the outpatients acquiring health education via face-to-face communication and written materials were significantly high in observation group than in control group(both P<0.01).Compared to those of control group,the outpatients of observation group reported significantly higher ratios of receiving specific guidance other than medication on daily diet,life style,mental health,cognition of pathogenic mechanism,and general health(all P<0.01).Significantly higher proportions of the outpatients of observation group than those of the control group reported practicing health behaviors including smoking cessation,reducing salt use,limiting oil consumption,oral health promotion,mental health promotion,reasonable medication,and disease self-management(P<0.01 for all).Significantly higher access of health education information and increase in health literacy were reported by the outpatients of observation group in comparison to those of control group(both P<0.01).Conclusion The medical record system-based electric health education prescription is effective in promotion of health attitude and behavior and disease self-management among clinic outpatients.

关 键 词：健康教育处方 门诊电子病历系统 信息化 

分 类 号：R197.323[医药卫生—卫生事业管理]