多学科协作管理模式提高病案首页主要诊断正确率的研究  

Research on Improving the Accuracy of Main Diagnostic Codes on the First Page of Medical Records by Multidisciplinary Collaborative Management Model

作　　者：刘玲[1] 陶源[1] 高旸昉 曹冬梅[1] 倪慧萍[1] LIU Ling;TAO Yuan;GAO Yangfang;CAO Dongmei;NI Huiping(Medical Record Room,the First People's Hospital of Changzhou,Changzhou Jiangsu 213000,China)

机构地区：[1]常州市第一人民医院病案室,江苏常州213000

出　　处：《中国卫生标准管理》2023年第14期6-10,共5页China Health Standard Management

基　　金：江苏省医院协会医院管理创新研究课题(JSYGY-1-2020-786)。

摘　　要：目的应用多学科协作管理模式对住院病案首页主要诊断进行管理,评价其应用效果。方法采取随机等距离抽样,抽取2020年1—6月2999份住院病案首页作为对照组,2021年1—6月2815份住院病案首页作为干预组。对比分析多学科协作管理模式实施前后病案首页主要诊断选择正确率、主要诊断编码正确率、主要诊断错误责任情况、主要诊断编码错误原因。结果某院实施多学科协作管理模式后,干预组的病案首页主要诊断选择正确率为89.17%,明显高于对照组的71.82%,差异有统计学意义(P<0.05)。干预组的主要诊断编码正确率为92.93%,明显高于对照组的73.26%,差异有统计学意义(P<0.05)。干预组的主要诊断选择正确率、主要诊断编码正确率较对照组均得到提高。实施多学科协作管理模式后,干预组的住院病案首页主要诊断错误责任类型均低于对照组,差异有统计学意义(P<0.05)。主要诊断编码为残余类目、肿瘤病历主诊选择错误、使用无效主诊断编码、以临终状态作为主诊在多学科协作管理模式实施后错误数量明显变少,差异有统计学意义(P<0.05)。结论多学科协作管理模式对提高病案首页主要诊断编码正确率有一定效果,值得推广。Objective The correct rate of the main diagnostic codes on the first page of the inpatient medical record is managed by using the multidisciplinary collaborative management mode,and its application effect is evaluated.Methods Random equidistant sampling was used to select 2 999 inpatient medical records from January to June 2020 as the control group,and 2 815 inpatient medical records from January to June 2021 as the intervention group.Compare and analyze the correct rate of main diagnosis selection,correct rate of main diagnosis coding,responsibility of main diagnosis errors and causes of main diagnosis coding errors on the first page of medical records before and after the implementation of multidisciplinary collaborative management mode.Results After the implementation of multi-disciplinary treatment mode in a hospital,the correct rate of main diagnosis selection on the first page of medical records in the intervention group was 89.17%,which was significantly higher than 71.82% in the control group,and the difference was statistically significant(P<0.05).The correct rate of main diagnosis code of intervention group was 92.93%,which was significantly higher than that of control group(73.26%),the difference was statistically significant(P<0.05).After implementation,the correct rate of main diagnosis selection and main diagnosis coding were improved compared with the control group.After the implementation of multidisciplinary treatment mode,in the intervention group,the types of responsibility for major diagnostic errors were significantly reduced compared with the control group,and the difference was statistically significant(P<0.05).The main diagnostic codes were residual categories,error selection of patients in tumor medical records,use of invalid primary diagnostic codes,and end-oflife status as the main diagnosis.After the implementation of the multidisciplinary collaborative management model,the number of errors decreased significantly,and the difference was statistically significant(P<0.05).Conclusion The

关 键 词：多学科协作 主要诊断 质量控制 病案首页 疾病编码 管理模式 

分 类 号：R197[医药卫生—卫生事业管理]