多学科协作模式在住院病案首页数据质量管理中的应用  

Application of Multi-disciplinary Team Mode in Data Quality Manage⁃ment of Inpatient Medical Record Homepage

作　　者：杨爱玲 赵利[1] 熊英[1] YANG Ailing;ZHAO Li;XIONG Ying(Medical Record Management and Information Statistics Center,Xiangya Hospital of Central South University,Changsha 410008,Hunan,China)

机构地区：[1]中南大学湘雅医院病案管理与信息统计中心,湖南长沙410008

出　　处：《中国卫生产业》2024年第21期25-28,共4页China Health Industry

摘　　要：目的 探讨多学科协作(multi-disciplinary team,MDT)模式在住院病案首页数据质量管理中的应用效果。方法 选取2021年7月—2024年6月中南大学湘雅医院负责病案首页填写与管理的40名医务人员为研究对象。2021年7月—2022年12月实施常规模式,设为对照组。2023年1月—2024年6月实施MDT模式,设为观察组。比较两组医务人员的工作质量、住院病案首页数据缺陷情况及质量评价。结果 观察组整体工作质量评分为(37.22±1.18)分,高于对照组的(35.99±1.26)分,差异有统计学意义(t=4.506,P<0.05)。观察组各分级病案首页数据缺陷率均低于对照组,观察组病案首页数据优秀率高于对照组,差异有统计学意义(P均<0.05)。结论 基于MDT模式对住院病案进行管理,可以提升病案管理人员的工作质量,减少病案首页数据缺陷,提升病案首页数据优秀率。Objective To explore the application effect of multi-disciplinary team(MDT)model in the data quality management of the first page of inpatient medical records.Methods Forty medical staff who were responsible for fill⁃ing in and managing the front page of medical records in Xiangya Hospital of Central South University from July 2021 to June 2024 were selected as the research objects.From July 2021 to December 2022,the conventional model was implemented and set as the control group.From January 2023 to June 2024,the MDT model was implemented and set as the observation group.The quality of work,data defects and quality of the first page of inpatient medical records were compared between the two groups.Results The overall work quality score of the observation group was 37.22±1.18,which was higher than 35.99±1.26 of the control group,and the difference was statistically significant(t=4.506,P<0.05).The defect rate of the first page data of all graded medical records in the observation group were lower than those in the control group,and the excellent rate of the first page data of the medical records in the observation group was higher than that in the control group,the differences were statistically significant(all P<0.05).Conclusion Based on the MDT model,the management of inpatient medical records can improve the work quality of medical record man⁃agers,reduce the data defects of the first page of medical records,and improve the data excellence rate of the first page of medical records.

关 键 词：住院病案 病案首页 质量管理 多学科协作 工作质量 数据缺陷 

分 类 号：R19[医药卫生—卫生事业管理]