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目的调查临床医护人员对病案信息资源的需求及服务建议。方法设计制定病案信息资源需求调查问卷,于2014年3月-2014年6月对河北省3所三级甲等综合医院的临床医护人员进行调查,了解临床医护人员对病案信息资源的需求状况,分析临床医护人员的需求特点及差异,并进一步征求服务建议。结果在信息需求方面,临床医师用于撰写论文、申报课题的比例高于临床护士(P<0.01),在积累知识方面低于临床护士(P<0.05)。临床医师选择病案信息年限跨度10年及以上的比例高于临床护士(P<0.01),选择出院1年内、5年内信息比例低于临床护士(P<0.01)。临床医师对病案首页、出入院记录、病程记录、检查化验的需求高于临床护士(P<0.01),对护理文件的需求低于临床护士(P<0.01)。在服务建议方面,临床医师在希望加强服务宣传方面低于临床护士(P<0.01),在选择咨询服务上低于临床护士(P<0.05)。结论根据临床医师和临床护士对病案信息的需求特点,改进病案服务模式,提供针对性服务,提高临床医护人员对病案信息资源的利用率。
Objective To investigate the demand and service suggestions of medical staff on medical record information resources. Methods The questionnaire of medical information resource requirements was designed and developed. From March 2014 to June 2014, clinical staff of three Grade A general hospitals in Hebei Province were surveyed to find out the demand of medical staff for medical information resources, Analyze the characteristics and differences of clinicians’ needs and further seek suggestions for their services. Results In terms of information needs, clinicians spent more time in writing essays than in clinical nurses (P <0.01), and less in clinical knowledge than in clinical nurses (P <0.05). Clinicians had a higher proportion of information records spanning 10 years and above than those of clinical nurses (P <0.01). Within one year of hospital discharge, the proportion of information within 5 years was lower than that of clinical nurses (P <0.01). The demand for nursing documents was lower than that of clinical nurses (P <0.01). Clinicians had higher requirements on clinical records, admission and admission records, course records and laboratory tests than clinical nurses (P <0.01). In terms of service recommendations, clinicians were lower than clinical nurses (P <0.01) in their desire to enhance service delivery and were lower than clinical nurses in choice counseling (P <0.05). Conclusion According to the demand characteristics of medical record information by clinicians and clinical nurses, the medical record service mode can be improved, and targeted services can be provided to improve the utilization rate of medical record information resources by clinicians.