中国全科医学Issue(4)：382-385,4.DOI:10.3969/j.issn.1007-9572.2016.04.004
社区慢性病患者电子健康档案真实性研究
Authenticity of Electronic Health Records of Community Chronic Disease Patients
摘要
Abstract
Objective To investigate the authenticity of electronic health records( EHRs)of community chronic disease patients,in order to provide corresponding suggestions for the quality management of community EHRs. Methods In August 2014,using simple random sampling method,we collected electronic health records of 500 chronic disease patients from Wutian Community Health Service Centre of Ouhai District in Wenzhou. Using 2013 Zhejiang Hytertension/ Diabetes Health Record Verification form revised according to the pre - survey results,we collected information from the included records,and the telephone interview was made on the patients. Results The rate of loss to follow - up was 35. 6% (178 / 500),and the authenticity rate of the records with complete follow - up was 70. 2% (226 / 322). The situation of unauthentic records was as follows:26(27. 1% )patients who had records of hypertension/ diabetes denied having hypertension/ diabetes;25(26. 0% ) patients who had physical examination records denied having physical examination;42(43. 8% )patients who had follow - up records denied having face - to - face follow - up;6(6. 3% )patients had≥3 follow - up items inconsistent with their answers;and 3(3. 1% )patients had physical records inconsistent with face - to face follow - up records. Conclusion The authenticity rate of the EHRs of chronic disease patients in the community health centers is low and the lost rate is high. Government should improve relevant policy;primary health care settings should strengthen supervision and management;people who establish records should participate in the quality assessment of EHRs,in order to improve the authenticity of EHRs.关键词
社区卫生服务/慢性病/电子健康病历/真实性Key words
Community health services/Chronic disease/Electronic health records/Authenticity分类
医药卫生引用本文复制引用
潘晓雅,刘妙兰,叶玉妹,王梦月,陈大庆..社区慢性病患者电子健康档案真实性研究[J].中国全科医学,2016,(4):382-385,4.基金项目
温州市公益性科技计划项目（Y20140635）---基于电子健康档案的社区居民慢性病管理现状及评价 （）
