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目的 了解上海市二、三级医院肿瘤化学药物治疗（以下简称“化疗”）质量情况，完善肿瘤化疗质量控制体系。方法 依据上海市肿瘤化疗质控中心督查方案，对全市103家从事肿瘤化疗的二、三级医院开展了2015年肿瘤化疗质量现场核查，采用SPSS 13.0进行数据汇总和分析。结果 上海市二、三级医院之间，肿瘤专业科室和非专业科室之间，肿瘤化疗病案的质量存在显著的不平衡，主要问题包括知情同意书内容不完整（33.04%），病理诊断不齐全或缺失（15.50%），肿瘤分期不规范或未分期（56.27%），化疗目的（42.44%）、化疗适应证（37.47%）和禁忌证（12.21%）不齐全或缺失，化疗疗效评价记录不全或未评价（24.10%），中期评估记录不全或未评价（27.72%），入院病史（16.28%）及化疗当日记录（32.04%）不完整或缺失等。结论 上海市医院肿瘤化疗病案的质量与医院的级别和是否为专科显著相关。各医院应该针对自身存在的问题，加强对化疗质量控制标准的学习。 |
| 关键词: 肿瘤 化疗 现场核查 质量控制 |
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| Current Status and Analysis of Cancer Chemotherapy Quality in Secondary and Tertiary Hospitals of Shanghai City |
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| Abstract: |
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Objective
To fully assess the status of cancer chemotherapy quality of secondary and tertiary hospitals in Shanghai in order to improve the quality control system of cancer chemotherapy. Method According to the supervision plan of Shanghai Cancer Chemotherapy Quality Control Center, all of the 103 secondary and tertiary hospitals in Shanghai which administrated chemotherapy to cancer patients have been inspected in 2015. SPSS13.0 was used for data aggregation and analysis. Result The cancer chemotherapy quality was significantly different between the secondary and tertiary hospitals, as well as between the oncology and non-oncology departments, the main problems were as follow: the informed consent content was incomplete (33.04%); pathological diagnosis was incomplete or missing (15.50%); tumor stage was not standardized or no staging (56.27%); the chemotherapy purposes (42.44%) and the chemotherapy indications (37.47%) and contraindications (12.21%) were incomplete or missing; the evaluation of chemotherapy efficacy was incomplete or not evaluated (24.10%); the mid-term assessment was incomplete or not evaluated (27.72%); admission history (16.28%) and records of the chemotherapy day (32.04%) were incomplete or missing. Conclusion The quality of medical records of cancer chemotherapy in Shanghai is significantly related to hospital level and specialty. The hospital authorities should learn the quality control standards based on their own problems. |
| Key words: cancer, chemotherapy, inspection, quality control |
