摘要
背景 全科医学科诊疗范围常涉及多系统、多器官疾病,申请会诊数量大,但目前关于全科医学科会诊现状的研究仍然较少.目的 收集三级综合医院全科医学科会诊相关资料,分析首都医科大学附属复兴医院全科医学科会诊现状,以提高首都医科大学附属复兴医院全科医学科会诊工作质量,为疾病的分级诊疗提供参考.方法 通过医院信息系统调取首都医科大学附属复兴医院 2021-2022 年全科医学科提请的会诊数据,对会诊基本情况、会诊科室、会诊原因、会诊诊断、会诊意见等进行分类总结.结果 2021-2022 年首都医科大学附属复兴医院全科医学科共收治住院患者 1 441 例,908 例有提请会诊记录,共计发出院内会诊 2 269 例次,执行会诊 1 966 例次,撤销会诊303 例次;已执行会诊中,男 987 例次,女 979 例次;年龄 17～101 岁,平均年龄(77.4±13.9)岁;共涉及 31 个临床科室,其中会诊次数最多的前 6 位科室分别为康复中心、耳鼻喉科、眼科、皮肤科、感染科及精神科;康复科、耳鼻喉科、眼科、皮肤科、感染科及精神科顺位排名第一的会诊诊断分别为功能障碍、感音神经性耳聋、白内障、皮炎、肺部感染及焦虑状态;会诊原因包括制定初始诊疗方案、调整当前诊疗方案、完善专科检查、专科协助治疗、进行专科评估等;会诊处理意见可大致分为专业评估、完善检查、明确诊断、药物治疗、临床操作、手术治疗、营养治疗、康复针灸.结论 全科医学科的诊疗范围包括各个系统常见病、多发病,会诊需求量大,会诊疾病谱体现了首都医科大学附属复兴医院全科医学科的临床需求和特点,分析会诊现状,有利于弥补全科诊疗短板,提高全科会诊工作质量,向全科与专科之间的转诊迈出第一步.
Abstract
Background The diagnosis and treatment of general practice often involve multi-system and multi-organ diseases,resulting in a large number of consultations.However,there is limited research on the current state of general practice consultation.Objective This study aims to collect relevant data on general practice consultation at Fuxing Hospital Affiliated with Capital Medical University,a tertiary general hospital and analyze the current situation of general practice consultation to improve the quality of general practice consultation at Fuxing Hospital and provide insights for hierarchical diagnosis and treatment.Methods The data of general practice consultation in Fuxing Hospital Affiliated to Capital Medical University from 2021 to 2022 were obtained through the hospital information system,and the basic information,consultation departments,consultation reasons,consultation diagnosis,and consultation opinions were classified and summarized.Results From 2021 to 2022,a total of 1 441 inpatients were admitted to the general practice department at Fuxing Hospital.Among them,908 inpatients had consultation records.A total of 2 269 in-hospital consultations were issued,966 consultations were executed while 303 were cancelled.Among the executed consultations,there were 987 males and 979 females.The age ranged from 17 to 101 years old,with an average age of(77.4±13.9)years old.A total of 31 clinical departments were involved,among which the top 6 departments with the most consultations were rehabilitation department,otolaryngology,ophthalmology,dermatology,infectious disease department and psychiatry.The most common diagnoses among these departments included dysfunction,sensorineural deafness,cataract,dermatitis,pulmonary infection and anxiety.The reasons for consultation included formulating initial treatment plans,adjusting current treatment plans,improving specialist examinations,assisting with specialized treatment and conducting specialist evaluations.The consultation treatment opinions can be roughly divided into professional evaluation,improving examinations,clarifying diagnosis,drug therapy,clinical operations,surgical treatment,nutritional therapy and rehabilitation acupuncture.Conclusion The diagnosis and treatment scope of general medicine includes common diseases and frequently occurring diseases in various systems,with a large demand for consultation.The spectrum of consultation diseases reflects the clinical needs and characteristics of the general medicine department of Fuxing Hospital Affiliated to Capital Medical University.Analyzing the current situation of consultation is conducive to making up for the shortcomings of general medicine,improving the quality of general consultation,and taking the first step towards referral between general medicine and specialists.
维普
万方数据