中国全科医学Issue(16)：1834-1836,3.DOI:10.3969/j.issn.1007-9572.2014.16.008
社区健康档案内容存在的缺陷及改进对策
Health Records Defects of Community Health Files and Countermeasures
边连朵 1王以新 1杨敏京 1冯妍 1李文靖1
作者信息
- 1. 100029 北京市，首都医科大学附属北京安贞医院大屯社区卫生服务中心
- 折叠
摘要
Abstract
Objective To investigate the quality status of health records in the community health centers and explore its influencing factors and improving countermeasures. Methods 420 health records in a community health service center in Bei-jing were randomly selected, and examined for the existing deficiencies according to the basic framework of health re-cords. Results The defect rates of disposal method,evaluation,objective data and subject data were 34. 0%(143/420), 30. 0%(126/420),10. 9%(46/420),9. 0%(38/420) respectively and no defective items were found about personal in-formation. Conclusion Each community health service center should strengthen the concept of general practice and carry out trainings to make health workers be aware of the importance of health records establishment. Secondly,the centers should build up community health records quality control system to guide and intervene with every step of the writing and the use of health records before and in the middle of file-writing. Thirdly,the administration of city and district community health service centers should emphasize guidance and assessment. Fourthly,it is imperative for National Health and Family Planning Commission of China to make new health records standards. In summary each part should work together to effectively improve the writing quality of health records,thus providing comprehensive raw materials for general medicine and medical institutions at all levels and laying a solid foundation for healthy and sustainable development of China's general medicine.关键词
健康档案/质量控制/全科医生/参考标准Key words
Health records/Quality control/General practitioner/Reference standards分类
医药卫生引用本文复制引用
边连朵,王以新,杨敏京,冯妍,李文靖..社区健康档案内容存在的缺陷及改进对策[J].中国全科医学,2014,(16):1834-1836,3.
