上海市某区外籍医师病历质量及影响因素分析

Medical record quality and Impact Factor Analysis of Foreign physicians from a District in Shanghai

目的:了解上海市某区外籍医生的病历质量情况及其主要影响因素,为外籍医师执业监管工作提供依据。方法:从2015年上海市某区208名外籍医师中,分层随机抽取60位医师的300份病历,利用广义线性混合模型分析外籍医师客观因素与病历质量之间的关系。结果:外籍医师的病历合格率为72.67%,扣分项目主要为一般项目、主诉、现病史和既往史,年龄和学历是病历质量的正向因素(P<0.05),专科医疗机构和美容科的外籍医师病历质量较差(P<0.05)。结论:外籍医师病历书写质量有待进一步提高,卫生行政部门应加强重视,应针对性地开展监督工作,并完善外籍医师病历质量评价标准。

Objective To learn the quality of medical records and the main influencing factors of foreign physicians from a district in Shanghai,for recommendation on the supervision of the practice of foreign physicians.Methods Sixty foreign physicians among a total of 208 from a district of Shanghai in 2015 were selected as the objects of study,and 300 medical records were randomly selected from stratified sampling.The generalized linear mixed model was used to analyze the factors influencing the quality of medical records of foreign physicians.Results The total qualified rate of medical records of foreign physicians was 72.67%.The main deduction items included general items,chief complaints,present and past medical history.Among the influencing factors affecting the quality of medical records,age and education were the positive factors（P〈0.05）,foreign physicians in specialist medical institutions were worse than in the comprehensive medical institutions（P〈0.05） and foreign physicians of cosmetology department were worse than the other departments in the quality of medical records（P〈0.05）.Conclusion The medical records of foreign physicians are of poor quality.Health administrative departments should pay more attention to supervision work in a targeted manner and improve the quality evaluation standards of medical records for foreign physicians.