北京市社区居民健康档案使用情况调查研究

目的研究分析北京市社区居民健康档案使用情况,探讨档案使用过程中存在的问题,为促进健康档案规范管理和有效使用提供参考依据。方法采用现场调查的方法,现场调查健康档案使用和利用情况。结果北京市社区卫生服务机构纸质家庭健康档案整体利用率、个人健康档案整体利用率和门诊纸质健康档案使用率分别为58.7%、38.3%和41.8%;健康档案记录形式以一般门诊记录为主;高血压、糖尿病、脑卒中、冠心病4种慢性病门诊健康档案使用率为50.8%,高于其他疾病健康档案使用率(28.5%),差异具有统计学意义(P<0.001);门诊电子健康档案主诉、检查、诊断、处理4项"完整记录"的比率为56.3%,日常门诊电子健康档案动态使用的比率为94.9%(包括记录不完整的电子健康档案)。结论北京市半数以上的社区居民家庭健康档案得到利用,没有成为"死档"。日常门诊对慢性患者使用健康档案明显高于其他疾病健康档案使用率,说明慢性病档案管理工作得到重视。使用电子档案的机构门诊电子档案使用率比较高,但电子完整记录率不高,提示健康档案规范管理工作还有待进一步加强。

Utilization status of health records in community health services stations in Beijing

Objective To understand the utility of health records in community health services stations in Beijing and to investigate the existing problems, so as to provide some referring evidences for improving health records management. Methods Field survey was conducted in the clinic of community health services centers. Results The utilization ratio of paper-based personal health records, family health records, health records in outpatient in community health service stations is 38.3%,58.7% and 41.8% respectively. The record form indicating specific service feature of general practice is relatively less than the common outpatient form. The utilization rates of health records of the four chronic diseases including high blood pressure, coronary heart disease, diabetes and stroke are higher than other cases,and the difference between the utilization rate of the four chronic diseases and other cases is statistically significant(P<0.001). The utilization of out-patient electronic health records is 94.9%. Among out-patient electronic health records, 56.3% are recorded systematically. Conclusion The majority of health records are used in community. The using rate is higher in health records of chronic diseases than that of other diseases. In electronic health records, many health records are recorded systematically, which indicates that management in health records should be strengthened furtherly.