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目的了解龙岩市肺结核患者的登记与治疗管理情况,为提高病历资料管理的完整性提供科学依据。方法根据2012年第一季度结核病季报表查阅第一季度涂阳肺结核患者病历资料的首张、疗程末胸片及病案资料。结果 171例涂阳肺结核患者首张胸片缺失4%,末张胸片缺失31%,扣除死亡及不良反应中断治疗占末张胸片缺失85%。结论病历资料中首张、疗程末X线胸片缺失严重应加强肺结核患者病历资料管理。
Objective To understand the registration and treatment management of pulmonary tuberculosis patients in Longyan City and provide a scientific basis for improving the integrity of medical record data management. Methods According to the first quarter of 2012 quarterly report of tuberculosis first quarter smear-positive pulmonary tuberculosis patient medical records first, end of treatment chest and medical records data. Results 171 cases of smear positive pulmonary tuberculosis patients with 4% of the first chest, 31% of the end of the absence of chest X-ray, after the deduction of death and adverse reactions accounted for 85% of the last missing chest X-ray film. Conclusion The first piece of medical history information, the end of the course of X-ray chest X-ray serious should strengthen the management of tuberculosis patients records data.