临床医护人员对病案信息资源需求现状的调查

Investigation on the Requirements Situation of Medical Records Information Resource Among Clinical Doctors and Nurses

目的调查临床医护人员对病案信息资源的需求及服务建议。方法设计制定病案信息资源需求调查问卷,于2014年3月-2014年6月对河北省3所三级甲等综合医院的临床医护人员进行调查,了解临床医护人员对病案信息资源的需求状况,分析临床医护人员的需求特点及差异,并进一步征求服务建议。结果在信息需求方面,临床医师用于撰写论文、申报课题的比例高于临床护士(P<0.01),在积累知识方面低于临床护士(P<0.05)。临床医师选择病案信息年限跨度10年及以上的比例高于临床护士(P<0.01),选择出院1年内、5年内信息比例低于临床护士(P<0.01)。临床医师对病案首页、出入院记录、病程记录、检查化验的需求高于临床护士(P<0.01),对护理文件的需求低于临床护士(P<0.01)。在服务建议方面,临床医师在希望加强服务宣传方面低于临床护士(P<0.01),在选择咨询服务上低于临床护士(P<0.05)。结论根据临床医师和临床护士对病案信息的需求特点,改进病案服务模式,提供针对性服务,提高临床医护人员对病案信息资源的利用率。

Objectives To investigate the requirements of medical records information resource among clinical doctors and nurses and relevant service advices. Methods Questionnaires were designed for the investigation of requirements of medical record information resources, then conducted a survey on the clinical staff of three Class A and Tertiary Comprehensive Hospital in Hebei Province from March to June in 2014, so as to get aware of the requirements situation of medical records information resource among clinical doctors and nurses, as well as analyzed the characters and differences among them, asked for further service advices of them. Results In terms of information requirements, the clinicians had higher proportion than nurses in papers writing and subject declaration（P〈0.01）, while lower than the clinical nurses in the accumulation of knowledge（P〈0.05）. The proportion of clinicians selected medical record information with age span of 10 years or more was higher than nurses（P〈0.01）,while lower in the selection of medical records information that discharged within 1 year or less than 5 years compared with nurses（P〈0.01）. The requirements for front pages of medical records, admission and discharge records, course records, check and laboratory results of clinicians were higher than clinical nurses（P〈0.01）,and lower than nurses in requirements of nursing documents（P〈0.01）. In the aspects of service advices, the requirement of clinicians was lower than the clinical nurses in the hope to strengthen service propaganda（P〈0.01）, and also lower than nurses in aspect of consulting services（P〈0.05）. Conclusions According to the requirements characters for medical record information of clinical doctors and nurses, we should improve the medical service mode, provide targeted services, and improve the utilization rate of medical record information resources among the clinical medical staff.