[1]闫柳清,唐 甜,郑 艳.四川省口腔医生对门诊病历书写项目的评价研究[J].医学信息,2024,37(04):102-107.[doi:10.3969/j.issn.1006-1959.2024.04.018]
　YAN Liu-qing,TANG Tian,ZHENG Yan.Evaluation Study of Outpatient Medical Record Writing Items by Dentists in Sichuan Province[J].Journal of Medical Information,2024,37(04):102-107.[doi:10.3969/j.issn.1006-1959.2024.04.018]
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四川省口腔医生对门诊病历书写项目的评价研究()
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医学信息[ISSN:1006-1959/CN:61-1278/R]

卷:
37卷
期数:
2024年04期
页码:
102-107
栏目:
论著
出版日期:
2024-02-15

文章信息/Info

Title:
Evaluation Study of Outpatient Medical Record Writing Items by Dentists in Sichuan Province
文章编号:
1006-1959（2024）04-0102-06
作者:
闫柳清; 唐 甜; 郑 艳
（四川大学华西口腔医院院办1，医务部2，四川 成都 610000）
Author(s):
YAN Liu-qing; TANG Tian; ZHENG Yan
(Hospital Office1,Medical Department2,West China School/Hospital of Stomatology Sichuan University,Chengdu 610041,Sichuan,China)
关键词:
口腔医生; 门诊病历; 重要性评价
Keywords:
Dentist; Outpatient medical record; Importance evaluation
分类号:
R197.323
DOI:
10.3969/j.issn.1006-1959.2024.04.018
文献标志码:
A
摘要:
目的 了解四川省口腔医生对门诊病历国家规定的书写项目和其它补充书写项目的重要性评价及差异，为探索建立统一的口腔专业门诊病历提供参考。方法 于2022年12月对四川省359家口腔医疗机构611名口腔医生进行问卷调查。重要性评价采用Likert 5级计分法，采用方差分析比较不同特征口腔医生对补充书写项目的评价差异。结果 口腔医生对口腔门诊病历国家规定的书写项目和补充书写项目（除身高和体重）的评分均≥4分；国家规定书写项目中评分最高的为主诉和诊断，补充书写项目中评分最高的为传染病史和牙科材料过敏史；不同职称、职务、工作年限和不同医疗机构的口腔医生对补充书写项目重要性评分比较，差异有统计学意义（P＜0.05）。结论 四川省口腔医生对门诊病历国家规定的书写项目和补充书写项目的评价均为重要。在国家规定的书写项目基础上，参考不同职称、职务和口腔医疗机构从业人员的建议和实际工作需要，将“饮食习惯、口腔卫生保健习惯、口腔定期检查、患者对口腔麻醉治疗的态度、传染病史、牙科材料过敏史”等有利于临床诊疗的书写项目纳入病历书写中，有利于建立更加全面的、适合口腔专业的口腔门诊病历。
Abstract:
Objective To understand the importance evaluation and differences between the national prescribed writing items and other supplementary writing items for outpatient medical records by dentists in Sichuan Province, and to provide reference for exploring the establishment of a unified outpatient medical record for stomatology.Methods In December 2022, a questionnaire survey was conducted among 611 dentists from 359 dental medical institutions in Sichuan province. The importance of outpatient medical record adopts the Likert 5-level scoring method. Analysis of variance was used to compare the differences in the evaluation of supplementary writing items by dentists with different characteristics.Results The average score of dentists on both the national prescribed writing items and supplementary writing items (except for height and weight) of oral outpatient medical records was≥4 scores. According to the national regulations, the highest scoring items in the writing items were the main complaint and diagnosis, while the highest scoring items in the supplementary writing items were the history of infectious diseases and the history of allergies to dental materials. There were statistically significant differences in the evaluation of supplementary writing items among dentists with different educational backgrounds, professional titles, positions, and from different medical institutions(P<0.05).Conclusion It is important for dentists in Sichuan province to evaluate both the national prescribed writing items and supplementary writing items for outpatient medical records. Based on the relevant national laws and regulations, and referring to the suggestions and actual work needs of employees from different professional titles, positions, and dental medical institutions, writing items that are conducive to clinical diagnosis and treatment, such as“dietary habits, oral health care habits, regular oral examinations, patients’ attitude towards oral anesthesia treatment, infectious disease history, and dental material allergy history”, are included in the medical record writing, which is conducive to establishing a more comprehensive dental outpatient medical records suitable for the dental profession.

参考文献/References:

[1]郑宇同,李建英,郑东翔.写好口腔专业门诊病历的重要性[J].中国病案,2011,12(8):13-15.[2]叶华军.口腔门诊病历的医院管理[J].河北医学,2009,15(7):882-883.[3]中华人民共和国卫生部.关于印发《病历书写基本规范》的通知[EB/OL].(2010-02-04)[2023-03-06].http://www.nhc.gov.cn/yzygj/s3585u/201002/0517a82e35224ee0912a5d855a9d249f.shtml.[4]中华人民共和国国家卫生和计划生育委员会.关于印发《医疗机构病历管理规定(2013年版)》的通知[EB/OL].(2013-12-17)[2023-03-06].http://www.nhc.gov.cn/yzygj/wslgf/201312/a84f3666d1be49f7a959d7912a978db7.shtml.[5]卢爱工,李莉莉,柳淑杰.口腔医护人员职业感染危险因素与对策[J].中华医院感染学杂志,2004,14(9):1079-1080.[6]杜飞,李榕,何睿,等.云南地区50岁及以上HIV感染者口腔损害流行情况分析[J].实用口腔医学杂志,2019,35(1):41-45.[7]解建立,汲平.口腔科材料引起的过敏反应[J].口腔颌面修复学杂志,2006,7(4):293-295.[8]马轩祥.修复体过敏症——修复中值得重视的问题[J].华西口腔医学杂志,2008,26(5):459-462.[9]王晓萍.齿科金属材料致敏性的比较及其与临床症状的相关性分析[D].上海:复旦大学,2013.[10]张明钰,郑先辉,徐艺坤.牙科材料相关过敏性接触性口炎临床特征与诊治分析[J].医学理论与实践,2023,36(1):91-93.[11]尹燕飞,李兴杰,张薇,等.饮食习惯在口腔健康管理中的重要性探讨[J].健康体检与管理,2022,3(1):69-72.[12]董艳丽,陈圆圆,李雪.口腔门诊969名患者饮食行为和口腔健康态度的调查分析[J].辽宁医学院学报,2012,33(5):451-452.[13]景欢,杨乐天,杨宏宇.不同年龄口腔科就诊患者的口腔保健意识及行为调查[J].医学信息,2022,35(19):46-50.[14]崔岳.口腔健康指导对重庆市城镇居民口腔保健意识影响的研究[D].重庆:陆军军医大学,2018.[15]陈珍,王玥,李海东,等.基于“PBL+O2O”混合教学模式的口腔医学研究生科研能力培养[J].西部素质教育,2023,9(3):101-104.[16]刘建国,白国辉,吴家媛,等.“学科引领-德智融合-协同育人”三位一体口腔医学研究生培养模式的探索与实践[J].浙江医学教育,2023,22(1):52-55.[17]陈园,黄俊,余日月.非口腔专业医护人员口腔保健知识及行为调查[J].实用医学杂志,2015,31(4):654-657.[18]史文宗,刘瑞吉,杨柳,等.医改新形势下病案的人文需求[J].医学信息,2020,33(5):19-21.[19]郭沫.口腔健康宣教对社区老年居民口腔健康和生理功能的影响评价[J].医学美学美容,2020,29(20):12-13.[20]Yenisey M.Comparison of the pain levels of computer-controlled and conventional anesthesia techniques in prosthodontic treatment[J].J Appl Oral Sci,2009,17(5):414-420.[21]王菲,赵阳阳,关明,等.静脉给药镇静技术在2582例口腔外科门诊手术中的临床应用[J].北京大学学报(医学版),2020,52(1):181-186. [22]黄春水,董颖韬.盐酸奥布卡因凝胶对拔牙患儿镇痛作用的评价[J].河北医药,2020,42(23):3636-3638.[23]潘剑,廖学娟,张壮.口腔医师应加强对门诊医疗突发事件的认知和处理能力[J].华西口腔医学杂志,2015,33(4):336-338.[24]刘柳,王翔,段宁,等.55例接触性口炎的致病因素及临床表现分析[J].口腔疾病防治,2021,29(6):388-394.[25]陈真.口腔医院医护人员对患者健康情况评估现状的分析[J].中医药管理杂志,2015,23(4):129-130.[26]左泽锦,陈川.2006-2009年医院医护人员手卫生监测效果评价[J].中华医院感染学杂志,2011,21(1):86-88.

更新日期/Last Update: 1900-01-01