关键词: 病案系统, 计算机化, 社区卫生服务, 深圳市

Abstract: Objective To analyze the EHR-related information of Bao’an residents in order to understand the present records status and provide basis for improvement of EHRs. Methods We aggregated EHR databases of each community health service centers, ruling out records with serious loss of registration information, or with logical errors, or waste records which had been unused for long. The eligible 1 088 773 records information in 2009—2010 was analyzed.Results Among the 1 088 773 cases of records, 491 324 were male and 597 449 were female with the ratio of 1∶1.22. Age group:<15 group of 37 902 cases, 15－ group of 587 039 cases, 30－ group of 386 980 cases, 45－ group of 53 938 cases, ＞60 group of 22 914 cases. The majority came from 15－45 age groups; the floating and temporary population accounted for 97.25%（1 058 854/1 088 773）；The medical expenses dominated by medical insurance for workers （680 053 cases， 62.46%）or at their own expenses(312 097cases，28.67%).As for disease spectrum, 4176, 16 588 and 3217 cases had diabetes, hypertension, tuberculosis respectively. Conclusion The structure of EHR is complete and large number of patients have built the records. However, there is some missing or incomplete information. Therefore, the accuracy and completeness of EHRs needs to be further improved.

Key words: Medical records systems,computerized, Community health services, Shenzhen city