糖尿病全科门诊结构化电子病历系统建设的研究

Study on the Structured Electronic Medical Record System for Diabetes Mellitus in General Clinics

目的建立糖尿病全科门诊结构化电子病历系统,评估使用效果。方法基于专家组论证的全科病历书写规范,结合糖尿病防治指南,建立糖尿病全科门诊结构化电子病历系统。选择2012年1月在五里桥街道社区卫生服务中心全科门诊就诊的糖尿病患者210例,采用随机数字表法分为2组,传统门诊病历组104例,全科医生沿用手工书写传统病历;全科电子病历组106例,全科医师使用结构化电子病历系统书写电子病历。观察基线及12个月后病史质量指标、医疗服务质量指标、血糖控制指标、满意度指标的变化。结果两组基线病史质量指标、医疗服务质量指标、血糖控制指标、满意度指标比较,差异均无统计学意义(P>0.05);12个月后全科电子病历组与传统门诊病历组比较,病史质量指标(完整病史率、合格病史率)、医疗服务质量指标(患者人均接诊时间、医生对病情和药物服用方法和注意事项说明率、及时就诊率、血糖监测及时率、处方合格率、健康宣教率)、血糖控制指标(空腹血糖、餐后2 h血糖、糖化血红蛋白水平)及满意度指标(患者满意度评分、医生满意度评分、医院管理者满意度评分)差异有统计学意义(P<0.05)。结论糖尿病全科门诊结构化电子病历系统有助于提高全科医生门诊工作质量和效率,有利于这一慢性病的良好稳定控制。

Objective To establish the structured electronic medical record system for diabetes mellitus in general clinics and evaluate the effects. Methods The structured electronic medical record system for diabetes mellitus was established based upon writing forms and after summarizing the expert opinions and suggestions. Follow - up surveys were extended to 210 dia- betic mellitus in the general clinics of Wuliqiao Community Health Service Center. Subjects were randomly divided into 2 groups u- sing different medical record systems. 104 cases were in the group using traditional clinic medical records. The other 106 cases were in the group using electronic medical records for general clinics. The base - line level and changes after 12 months were ana- lysed. The evaluation indexes included level of medical history, medical service indexes, control indexes of diabetes and satisfac- tion indexes. Results No significant differences existed between the two groups concerning baseline level of medical history, medical service indexes, control indexes of diabetes and satisfaction indexes （P 〉 0. 05 ） . Compared with the group using tradi- tional medical records, after the 12 -month survey, the electronic record system -aided group＇s evaluation indexes including ra- tio of completed history, ratio of qualified history, reception time per patient, illness explanation ratio, therapy explanation rati- o, timely treatment rate, timely monitoring rate of blood glucose, qualified prescription ratio, the proportion receiving health ed- ucation, fasting blood glucose, 2 - hour postprandial blood glucose, glycosylated hemoglobin, patients＇ satisfaction, family doctors＇ satisfaction, administrators＇ satisfaction had all increased （ P 〈 0. 05 ） . Conclusion The structured electronic medical record system for diabetes mellitus in general clinics improved the management quality and efficiency.