四川省口腔医生对门诊病历书写项目的评价研究  

Evaluation Study of Outpatient Medical Record Writing Items by Dentists in Sichuan Province

作　　者：闫柳清 唐甜[1] 郑艳 YAN Liu-qing;TANG Tian;ZHENG Yan(Hospital Office,West China School/Hospital of Stomatology Sichuan University,Chengdu 610041,Sichuan,China;Medical Department,West China School/Hospital of Stomatology Sichuan University,Chengdu 610041,Sichuan,China)

机构地区：[1]四川大学华西口腔医院院办,四川成都610000 [2]四川大学华西口腔医院医务部,四川成都610000

出　　处：《医学信息》2024年第4期102-107,共6页Journal of Medical Information

基　　金：四川大学华西口腔医院软科项目(编号:RD-01-202008)。

摘　　要：目的了解四川省口腔医生对门诊病历国家规定的书写项目和其它补充书写项目的重要性评价及差异,为探索建立统一的口腔专业门诊病历提供参考。方法于2022年12月对四川省359家口腔医疗机构611名口腔医生进行问卷调查。重要性评价采用Likert 5级计分法,采用方差分析比较不同特征口腔医生对补充书写项目的评价差异。结果口腔医生对口腔门诊病历国家规定的书写项目和补充书写项目(除身高和体重)的评分均≥4分;国家规定书写项目中评分最高的为主诉和诊断,补充书写项目中评分最高的为传染病史和牙科材料过敏史;不同职称、职务、工作年限和不同医疗机构的口腔医生对补充书写项目重要性评分比较,差异有统计学意义(P<0.05)。结论四川省口腔医生对门诊病历国家规定的书写项目和补充书写项目的评价均为重要。在国家规定的书写项目基础上,参考不同职称、职务和口腔医疗机构从业人员的建议和实际工作需要,将“饮食习惯、口腔卫生保健习惯、口腔定期检查、患者对口腔麻醉治疗的态度、传染病史、牙科材料过敏史”等有利于临床诊疗的书写项目纳入病历书写中,有利于建立更加全面的、适合口腔专业的口腔门诊病历。Objective To understand the importance evaluation and differences between the national prescribed writing items and other supplementary writing items for outpatient medical records by dentists in Sichuan Province,and to provide reference for exploring the establishment of a unified outpatient medical record for stomatology.Methods In December 2022,a questionnaire survey was conducted among 611 dentists from 359 dental medical institutions in Sichuan province.The importance of outpatient medical record adopts the Likert 5-level scoring method.Analysis of variance was used to compare the differences in the evaluation of supplementary writing items by dentists with different characteristics.Results The average score of dentists on both the national prescribed writing items and supplementary writing items(except for height and weight)of oral outpatient medical records was≥4 scores.According to the national regulations,the highest scoring items in the writing items were the main complaint and diagnosis,while the highest scoring items in the supplementary writing items were the history of infectious diseases and the history of allergies to dental materials.There were statistically significant differences in the evaluation of supplementary writing items among dentists with different educational backgrounds,professional titles,positions,and from different medical institutions(P<0.05).Conclusion It is important for dentists in Sichuan province to evaluate both the national prescribed writing items and supplementary writing items for outpatient medical records.Based on the relevant national laws and regulations,and referring to the suggestions and actual work needs of employees from different professional titles,positions,and dental medical institutions,writing items that are conducive to clinical diagnosis and treatment,such as“dietary habits,oral health care habits,regular oral examinations,patients'attitude towards oral anesthesia treatment,infectious disease history,and dental material allergy history”,are includ

关 键 词：口腔医生 门诊病历 重要性评价 

分 类 号：R197.323[医药卫生—卫生事业管理]