CAJ | 학술논문

目的：了解社区卫生服务中心健康档案的质量现状，探讨影响健康档案质量的因素和提高健康档案质量的对策。方法于2011年7月-2013年6月选取北京市某社区卫生服务中心健康档案420份，根据健康档案基本框架要求进行检查，找出存在的缺陷。结果健康档案内容缺陷率分别是处理计划34.0％（143/420）、评价30.0％（126/420）、主观资料10.9％（46/420）、客观资料9.0％（38/420），个人基本情况没有缺陷项目。结论各个社区卫生服务中心应加强全科理念和健康档案重要性的培训，建立社区健康档案质量控制管理体系，从健康档案形成前、形成过程中对书写与使用进行引导和干预；市区两级社区卫生服务管理中心应加强对健康档案管理工作的指导与考核；卫计委要尽快研究制定新的健康档案标准规范。通过各级部门共同努力，切实提高健康档案书写质量，为全科医学、各级医疗提供完善的原始资料，为我国全科医学的健康持续发展奠定扎实基础。
목적：료해사구위생복무중심건강당안적질량현상，탐토영향건강당안질량적인소화제고건강당안질량적대책。방법우2011년7월-2013년6월선취북경시모사구위생복무중심건강당안420빈，근거건강당안기본광가요구진행검사，조출존재적결함。결과건강당안내용결함솔분별시처리계화34.0％（143/420）、평개30.0％（126/420）、주관자료10.9％（46/420）、객관자료9.0％（38/420），개인기본정황몰유결함항목。결론각개사구위생복무중심응가강전과이념화건강당안중요성적배훈，건립사구건강당안질량공제관리체계，종건강당안형성전、형성과정중대서사여사용진행인도화간예；시구량급사구위생복무관리중심응가강대건강당안관리공작적지도여고핵；위계위요진쾌연구제정신적건강당안표준규범。통과각급부문공동노력，절실제고건강당안서사질량，위전과의학、각급의료제공완선적원시자료，위아국전과의학적건강지속발전전정찰실기출。
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.