基于MDT模式的病案管理方案对住院病案管理质量及病案缺陷的影响  

Influences of medical record management scheme based on MDT mode on the quality of inpatient medical record management and medical record defects

作　　者：崔强 CUI Qiang(Medical Record Department,Henan Province People's Hospital,Zhengzhou 450000,China)

机构地区：[1]河南省人民医院病案科,河南郑州450000

出　　处：《临床医学研究与实践》2023年第2期170-172,共3页Clinical Research and Practice

摘　　要：目的 探讨基于多学科团队诊疗(MDT)模式的病案管理方案对住院病案管理质量及病案缺陷的影响。方法 根据本院住院病案信息填写规范,由专职人员按专科每月15%的比例在基于MDT模式的病案管理方案实施前的2020年1月至6月和实施后的2020年7月至12月,随机抽取住院病案,进行质量的考核工作,共计抽取实施前6 358份,实施后6 507份。比较实施前、后的住院病案管理质量、等级及缺陷情况。结果 实施后,病案首页、病程记录、辅助检查评分均高于实施前,整体病案等级情况明显优于实施前,主要诊断填写错误、其他诊断遗漏、主要手术和操作填写错误、联系人填写错误、地址不精确、身份证号缺失、职业填写错误及重要指标漏填的占比均低于实施前(P<0.05)。结论 基于MDT模式的病案管理方案有助于提高住院病案管理质量,降低病案缺陷率。Objective To explore the influences of medical record management scheme based on multidisciplinary team(MDT) mode on the quality of inpatient medical record management and medical record defects. Methods According to the filling standard of inpatient medical record information in our hospital, full-time personnel randomly selected inpatient medical records from January to June 2020 before the implementation of the medical record management scheme based on MDT mode and from July to December 2020 after the implementation according to the proportion of 15% per month in the specialty, and conducted quality assessment. A total of 6 358 copies before the implementation and 6 507 copies after the implementation were selected. The quality, grade and defects of inpatient medical record management before and after implementation were compared. Results After implementation, the scores of the first page of the medical record, the course record and the auxiliary examination were higher than those before implementation, the overall medical record level was significantly better than that before implementation, and the proportion of major diagnosis filling errors, other diagnosis omissions, major surgery and operation filling errors, contact filling errors, inaccurate address, missing ID number,occupational filling errors and missing important indicators were lower than those before implementation(P <0.05).Conclusion The medical record management scheme based on MDT model is helpful to improve the quality of inpatient medical record management and reduce the defect rate.

关 键 词：多学科团队诊疗模式 病案管理 住院病案管理质量 病案缺陷 

分 类 号：R197.323[医药卫生—卫生事业管理]