阴道镜报告必备要素描述规范性分析  

Analysis of the standardization in describing essential elements of colposcopy reports

作　　者：王小军 毕蕙[1] WANG Xiaojun;BI Hui(First Hospital of Peking University,Beijing 100034,China;Xiaodian District Maternal and Child Health Care and Family Planning Service Center,Taiyuan 030032,Shanxi Province,China)

机构地区：[1]北京大学第一医院,北京100034 [2]太原市小店区妇幼保健计划生育服务中心,山西太原030032

出　　处：《中国妇幼卫生杂志》2025年第2期146-149,共4页Chinese Journal of Women and Children Health

摘　　要：目的 通过对阴道镜报告必备要素描述规范性的分析,了解目前阴道镜检查报告描述的规范性,为提高阴道镜检查质量提供依据。方法 收集来自不同医疗机构阴道镜检查报告资料,对报告中必备要素描述的规范性进行分析。结果 共收集159份来自全国17个省(直辖市、自治区)159家医疗机构的阴道镜检查报告,其中88.1%的报告中标明了接受阴道镜检查的指征。在81份(50.9%)有完整鳞柱交界与转化区类型描述的报告中,有70份(86.4%)二者描述相符。有137份(86.2%)报告中描述了活检取样情况,其中60.6%(83/137)为阴道镜下所见异常区域的多点定位活检。57.9%(92/159)阴道镜报告中有明确的进一步处理建议。结论 目前,医疗机构阴道镜报告的规范性仍显不足,应进一步加强对阴道镜医师的规范性培训以及对阴道镜检查的质量控制。Objective To assess the standardization of essential elements in colposcopy report by analyzing their descriptive consistency,and to provide a basis for improving the quality of colposcopy.Methods The data of colposcopy reports from various medical institutions were collected and analyzed for the standardization of essential elements described in the reports.Results A total of 159 colposcopy reports were collected from 159 medical institutions across 17 provinces in China,with 88.1%of the reports documenting the indications for colposcopy.Among the 81 reports(50.9%)that provided complete descriptions of squamocolumnar junction and transformation zone types,70(86.4%)showed consistency between the two descriptions.Biopsy sampling situation was described in 137 reports(86.2%),among which 60.6%(83/137)involved multiple-site biopsies of abnormal areas observed during colposcopy.Furthermore,57.9%(92/159)of the colposcopy reports included clear recommendations for further management.Conclusion Currently,the standardization of colposcopy reports in medical institutions remains inadequate.Further standardized training for colposcopy physicians to enhance quality control of colposcopy should be strengthened.

关 键 词：阴道镜检查报告 规范性 子宫颈癌 

分 类 号：R737.33[医药卫生—肿瘤]