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目的了解天津市医疗机构传染病报告质量和工作现状,为提高传染病报告质量提供参考依据。方法调查各区(县)医疗机构2013年1—9月门诊、住院病历,二、三级医疗机构抽查门诊病例20例和住院病例5例,一级医院抽查门诊病例10例。核对抽查病例所在医院的门诊住院病例登记、传染病卡片、网络直报系统电子卡片三者之间信息,计算传染病漏报率、及时报告率、报告卡填写完整率和准确率、报告卡与网络报告信息一致率。结果调查传染病690例,总漏报率2.17%,乙、丙类传染病漏报率分别为2.33%和1.97%(χ2=0.10,P=0.75)。及时报告率99.11%,纸质报告卡填写完整率98.67%,纸质报告卡填写准确率75.56%,网络报告信息一致率93.93%。结论天津市2013年传染病总漏报率较低,各医疗机构电子病历系统使用情况差别较大,报告质量有待提高,需加强督导和培训力度,完善电子病历的应用,从而减少漏报病历,提高医疗机构法定传染病报告率。
Objective To understand the quality and status quo of infectious disease reporting in medical institutions in Tianjin and provide reference for improving the quality of infectious disease reporting. Methods To investigate the outpatient and inpatient medical records from January to September in 2013 in all districts (counties) and 20 outpatients and 5 inpatients in the second and third class medical institutions, and 10 outpatients in the first class hospitals. Check the outpatient inpatient hospital registration, infectious disease card, network direct reporting system electronic card information of the hospital where the random sample is located, calculate the rate of omission of infectious disease, timely reporting rate, completeness and accuracy of report card, report card and Network report information consistency rate. Results 690 cases of infectious diseases were investigated, with a total false negative rate of 2.17%. The false negative rates of infectious diseases of class B and C were 2.33% and 1.97%, respectively (χ2 = 0.10, P = 0.75). 99.11% of the time reporting rate, 98.67% completion rate of paper report card, 75.56% accuracy rate of paper report card, and 93.93% of online report information. Conclusion In 2013, the total missed rate of infectious diseases in Tianjin was relatively low, the use of electronic medical record systems in various medical institutions varied greatly and the quality of reports needed to be improved. Supervision and training should be strengthened to improve the application of electronic medical records so as to reduce the omission of medical records, Improve the reporting rate of notifiable infectious diseases in medical institutions.