MDT模式在终末病案质量控制中的应用与评价  

Evaluation and Application Exploration of MDT Mode in Quality Control of the Final Medical Records

作　　者：宋文兰[1] SONG Wenlan(Medical Records Room,Medical Department,Dongtai People's Hospital,Dongtai 224200)

机构地区：[1]江苏省东台市人民医院医务科病案室,东台224200

出　　处：《解放军医院管理杂志》2021年第10期941-943,共3页Hospital Administration Journal of Chinese People's Liberation Army

摘　　要：目的分析临床多学科模式(MDT)在终末病案质量控制中的应用效果。方法根据《江苏省住院病例质量评定标准(2016年版)》,由病案质控员,每月随机按照比例抽取病案资料进行终末病案质控。将2020年9月1日—12月31日组定义为MDT实施前组,2021年1月1日—4月30日组定义为MDT实施后组,对比2组甲级病案率、入院记录书写规范率、首次病程记录规范率、出院记录书写规范率和各种缺陷构成。运用SPSS21软件对数据进行统计分析,P<0.05认为具有统计学差异。结果MDT模式实施后甲级病案率、入院记录书写规范率、首次病程记录规范率、出院记录书写规范率均明显高于实施前,患者首页基本信息填写不全、首页填写不规范等项目缺陷率较实施前期组降低,差异具有统计学意义(P<0.05)。结论MDT模式通过成立组织、强化学习培训、建立有效的质控体系、增强医务人员法律意识、利用信息化手段提质增效、构建交流平台、建立绩效考核和奖惩机制等,使多部门共同参与和监管,达到病案内涵质量提升、病案首页质量改进的效果。Objective To analyze the application effect of clinical multidisciplinary treatment in the quality control of the final medical records. Methods According to the quality evaluation standard for inpatients in Jiangsu Province(2016 version),the medical record quality controllers selected the medical record data in proportion every month for final medical record quality control. The group from September 1 st to December 31 st of 2020 was defined as the pre-implementation MDT group and the group from January 1 st to April 30 th was defined as the post-implementation MDT group. The class medical record rate, standardized writing rate of admission records, standard rate of first course record, the writing standard rate of discharge records and defect composition of the final medical records of the two groups were compared. SPSS 21 was used for statistical analysis of the data, and the difference was statistically significant(P<0.05). Results After the implementation of MDT, the class medical record rate, standardized writing rate of admission records, standard rate of first course record, and the writing standard rate of discharge records were significantly higher than that before the implementation, and the defect rate of the incompleteness of the basic information on the patient’s home page and the first page of the medical record filled out irregularly was significantly lower than that before the implementation. Conclusion Through perfecting the organizational structure, strengthening personnel training, establishing effective quality control system, enhancing the legal awareness of medical personnel, using information technology to improve quality and efficiency, building communication platform, establishing rewards and punishment mechanism, making a multi-sectoral joint participation, mutual supervision, MDT can achieve the connotation and quality improvement of medical record content and quality improvement of first page of medical record.

关 键 词：MDT 住院终末病案 质量控制 

分 类 号：R197.32[医药卫生—卫生事业管理]