中国全科医学Issue(16)：1837-1840,4.DOI:10.3969/j.issn.1007-9572.2014.16.009
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
摘要
Abstract
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.关键词
糖尿病/病案系统,计算机化/社区卫生服务Key words
Diabetes/Medical records systems,computerized/Community health services分类
医药卫生引用本文复制引用
李昱东,李文昌,陈玲,龚幼龙,邵红美..糖尿病全科门诊结构化电子病历系统建设的研究[J].中国全科医学,2014,(16):1837-1840,4.基金项目
上海市卢湾区科学技术委员会课题（ LKW1014）；上海市卢湾区卫生局课题 （）
