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

    潘晓雅，刘妙兰，叶玉妹，王梦月，陈大庆

    【摘要】目的了解社区慢性病患者电子健康档案的真实性，为社区电子健康档案质量管理提出相应建议。方法于2014年8月，采用简单随机抽样的方法，在温州市瓯海区梧田街道社区卫生服务中心抽取慢性病患者电子健康档案500份。采用根据预调查修改后的浙江省2013年版《高血压/糖尿病患者健康档案核查表》对纳入档案进行信息收集，同时对纳入档案患者进行电话访问。结果500份电子健康档案的失访率为35.6%(178/500)，322份未失访档案的真实率为70.2%(226/322)。档案不真实原因分别为：患者否认患高血压/糖尿病而有高血压/糖尿病档案26份(27.1%)、未进行体检而有体检记录25份(26.0%)、未进行面对面随访而有随访记录42份(43.8%)、末次随访记录中≥3项与回答不符6份(6.3%)、体检记录和面对面随访记录均不符3份(3.1%)。结论社区慢性病患者电子健康档案的失访率较高、真实率较低。建议政府部门加大政策投入、基层医疗机构加强监督管理、建档者参与档案的质量评估，共同改善档案的真实性现状。

    【关键词】社区卫生服务；慢性病；电子健康病历；真实性

    潘晓雅，刘妙兰，叶玉妹，等.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，2016，19(4)：382-385.[www.chinagp.net]

    Pan XY,Liu ML,Ye YM,et al.Authenticity of electronic health records of community chronic disease patients[J].Chinese General Practice，2016，19(4)：382-385.

    Authenticity of Electronic Health Records of Community Chronic Disease PatientsPANXiao-ya,LIUMiao-lan,YEYu-mei,etal.DepartmentofChronicDiseaseManagement,CommunityHealthServiceCenterofOuhaiDistrict,Wenzhou325014,China

    【Abstract】ObjectiveTo 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.MethodsIn 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.ResultsThe 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.ConclusionThe 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. ......