Reasons for encounters, investigations, referrals, diagnoses and treatments in general practice in Sweden-a multicentre pilot study using electronic patient records
Reasons for encounters, investigations, referrals, diagnoses and treatments in general practice in Sweden-a multicentre pilot study using electronic patient records
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DOI：
10.3109/13814788.2010.538675
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发表时间：
2011-06-01
影响因子：
3.4
通讯作者：
Bjorkelund, Cecilia
中科院分区：
文献类型：
--
作者：
Mansson, Jorgen;Nilsson, Gunnar;Bjorkelund, Cecilia
目的：调查的原因，遇到，调查，转诊，诊断和治疗在日常的一般做法，使用电子病历（EPR），以及有关性别，社会经济地位（SES）和实践的位置可能相关的差异。方法：四个瑞典初级保健中心使用EPR参与。登记了症状、检查、诊断和处方药物的分布情况。结果：在1055次就诊中，平均患者年龄为53岁; 59%为女性。最常见的原因是肌肉骨骼（21.5%）和呼吸系统（15.2%）症状。共编码了1534个诊断，平均每次1.5个。主要的诊断组，即ICD-10章节，是肌肉骨骼（17.2%）和呼吸系统（12.4%）。最常见的具体诊断是原发性高血压（8.1%）和急性上呼吸道感染（3.7%）。共开出1687张处方，平均每次1.6张。最常见的药物组为神经系统（17.7%）、呼吸系统（16.2%）和心血管系统（15.7%）。最常见的药物是苯氧甲基青霉素（3.7%）、双氯芬酸（2.9%）和乙酰水杨酸（2.5%）。平均每次就诊进行1.3次实验室检查。在7.5%的就诊中，进行了放射学转诊;在12.3%的就诊中，向其他专家/治疗师转诊，而在11.7%的就诊中，开具了疾病清单证明。有显着差异，女性和男性患者之间的症状，诊断和调查，城市和农村的做法和SES.Conclusion：肌肉骨骼，呼吸和循环系统占主导地位，无论是作为遇到的原因和诊断，但性别，SES和实践的位置有显着差异。
Objective : To investigate reasons for encounters, investigations, referrals, diagnoses and treatments in everyday general practice, using electronic patient records (EPR), and possible related differences concerning gender, socio-economic status (SES) and practice location. Method : Four Swedish primary care centres using EPR participated. Distributions of symptoms, investigations, diagnoses and prescribed drugs were registered. Results : In 1055 encounters, the mean patient age was 53; 59% were women. The most common reasons for the encounter were musculoskeletal (21.5%) and respiratory (15.2%) symptoms. A total of 1534 diagnoses were coded, on average 1.5 per encounter. The predominant diagnostic groups, i.e. ICD-10 chapters, were musculoskeletal (17.2%) and respiratory (12.4%). The most common specific diagnoses were essential hypertension (8.1%) and acute upper respiratory infections (3.7%). A total of 1687 prescriptions were issued, on average 1.6 per encounter. The most frequent pharmaceutical groups were nervous (17.7%), respiratory system (16.2%), and cardiovascular (15.7%). The most frequent drugs were phenoxymethyl penicillin (3.7%), diclofenac (2.9%) and acetylsalicylic acid (2.5%). An average of 1.3 laboratory tests was performed per encounter. In 7.5% of encounters, radiology referrals were made; in 12.3% referrals were made to other specialists/therapists, while sick-list certificates were written in 11.7%. There were significant differences concerning symptoms, diagnoses and investigations between female and male patients, urban and rural practices and SES.Conclusion: The musculoskeletal, respiratory and circulatory systems predominated, both as reasons for the encounter and in the diagnoses, but with significant differences concerning gender, SES and practice location.