东莞市某社区居民电子健康档案管理现状调查

Current situation of standardized management of electronic health records of residents in Dongguan

目的调查东莞市某社区卫生服务中心居民电子健康档案规范化管理现状,并探讨相关对策。方法对东莞市某社区卫生服务中心保存的居民电子健康档案进行系统抽样调查,了解居民电子健康档案完整性、使用情况、活化情况等。结果共抽取居民电子健康档案350份,一般资料表、健康体检表不合格率分别为4.57%和11.43%;在健康档案动态试用调查中,高血压或糖尿病居民动态使用率最高,一般居民动态使用率最低,常用于健康体检;东莞市户籍常住人员、非东莞市户籍常住人员、非常住人员之间的1年活化率、2年活化率差异有统计学意义(P<0.05)。结论东莞市社区卫生服务中心在管理居民电子健康档案工作合格率、活化率较高,但也存在信息更新不及时、居民配合度不足、管理不到位等问题。

objective To investigate the current situation of standardized management of electronic health records of res-idents in a grass-roots community health service center in Dongguan and analyze relevant countermeasures.Methods Ten primary community health service centers in Dongguan were selected as the research objects.A systematic sam-pling survey was conducted to investigate the integrity,usage and activation of residents'electronic health records.Re-sults In the study,350 electronic health records of residents were selected,and the unqualified rates of general data sheet and physical examination form were 4.57%and 11.43%respectively.In the dynamic trial survey of health records,the dynamic utilization rate of residents with hypertension or diabetes was the highest,and the dynamic utiliza-tion rate of general residents was the lowest,which was commonly used for physical examination.Permanent residents(Dongguan household registration),permanent residents(non Dongguan household registration),non permanent resi-dents(non Dongguan household registration).There were significant differences in 1 year activation rate and 2 years ac-tivation rate between residents(P<0.05).Conclusions A community health service center in Dongguan has a high qualification rate and activation rate in the management of residents'electronic health records,but there are also prob-lems such as untimely update of information,insufficient cooperation of residents,and inadequate management.