宫颈癌筛查中宫颈细胞学异常患者的门诊病案管理

Outpatient Medical Records Management for Patients with Abnormal Cervical Cytology in the Screening of Cervical Cancer

目的为宫颈细胞学异常的患者建立一整套规范、完整的门诊病案,便于患者的随访和治疗,同时也为临床积累了丰富的医疗资料。方法对在2008年4月-2009年2月期间,北京市两癌筛查中的宫颈细胞学异常到阴道镜门诊就诊的281例患者,给予阴道镜检查及手术治疗,同时将所有资料进行整理、分析、归档,建立完整门诊病案。结果宫颈癌前期病变中的高级别的宫颈病变患者(CIN2-3)71例,宫颈癌伴早期浸润4例,经宫颈LEEP术后治愈4例,经宫颈LEEP术后组织病理学为宫颈癌Ib2患者入本院妇科或转院切除子宫。高级别的宫颈病变患者的随访率100%。结论(1)建立系统的宫颈细胞学异常患者门诊病案管理是提高阴道镜门诊的诊治、管理水平的前提。(2)宫颈癌占妇女癌症第二位,加强对广大妇女进行的两癌筛查工作意义重大。

Objective To establish a set of standard and complete outpatient medical records for patients with abnormal cervical cytology,which is convenient for the treatment and follow-up visit.Methods Outpatient medical records were established for 281 patients with abnormal cervical cytology from April,2008 to February,2009.Their data were analyzed.Results High-grade cervical lesions（CIN2-3） were found in 71 patients,and early invasive cervical cancer in 4 cases.After cervical LEEP,four cases were healed;patients whose histopathology was Ib2 were admitted into department of gynecology or transferred to other hospital for hysterectomy.The follow-up rate for patients with high-grade cervical lesions was 100%.Conclusion Establishment of systematic outpatient medical records for patients with abnormal cervical cytology was the premise for improving the diagnosis and treatment of cervical cancer which accounted for the second cancer of women.