Skráning og vinnsla samskipta á heilsugæslustöðinni á Hólamvík 1. júlí 1985 til 30. júní 1986

Þorsteinn Njálsson

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Abstract

The article describes the changeover from older form of medical records to a new problem-oriented medical record system, the so-called Egilsstadir-medical records. One year of the new medical record is reviewed after it had been computerized. Communication notes are written for each contact the individual has with the health center. It includes name, date of birth, when and how the contact was made, and the reason, the diagnosis and the solution of problems. The reason, the diagnosis and the solution were coded for later computerization according to the ICHPPC-2, International Classification of Health Problems in Primary Care, which is based on an adaptation of ICD-9. The material from a twelve month period, July 1st 1985 to June 30th 1986, is presented. This material represents the communications of a population of 983 with the health center in Hólmavík, a rural district on the north-west peninsula of Iceland, and because of it's isolation, probably represents almost all communications of this population with the health care system. The age-distribution of the population in the district is similar to Iceland as a whole. In a one year period 89.2% of the population contacted the health staff in the area. It equals that on the average each person contacted the health staff 5.1 times, 3.9 for men and 6.4 for women. There were 4974 contacts made for 5217 reasons. The most common complaint was pain in limbs and abdomen. Symptoms of diseases accounted for 49% of all the reasons for contacting the health center, followup 15.4%, prescriptions 14%, preventive health measures 7.3%, accidents 1.6% and other reasons 12.7%. Table III gives account of all diagnoses, but the most common diagnosis was cardiovascular disease. Prescriptions were the most common of all solutions, 47%. The Egilsstadir-medical record has in my opinion proved its benefit and use. Its simplicity gives an enormous opportunity for wide research and comparison of various health centers.
Grein þessi nær til eins árs skráningar á Heilsugæslustöðinni á Hólmavík frá 1.7. 1985 til 30. 6. 1986. Íbúar eru 983 og samskipti áttu 89,2% á þessum tíma, alls í 4974 skipti, eða 5,1 samskipti á íbúa. Lýst er aðferðum við skráningu og uppsetningu Egilsstaðakerfisins (1) við heilsugæslustöðina. Hiklaust er hægt að segja, að Egilsstaðakerfið hafi sannað gildi sitt. Það gefur kost á skemmtilegri og aðgengilegri vandamiðaðri sjúkraskrá ásamt möguleika á tölvufærslu. Víða um land er nú þegar byrjað að safna upplýsingum af samskiptaseðlum í tölvur og vonar greinarhöfundur að þessi skrif verði læknum hvatning til að skoða upplýsingasafn sitt og jafnvel að koma því á framfæri.
Original languageIcelandic
JournalLæknablaðið
Publication statusPublished - 15 Sep 1988

Other keywords

  • Samskipti
  • Heilsugæsla
  • Skráning gagna

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