MDT模式在住院病案首页质量管理中的应用

Application Exploration of MDT Mode in Quality Management of the Front Pages of Medical Records

目的探讨临床多学科团队诊疗(MDT)在住院病案首页质量管理中的应用价值,为住院病案首页质量持续改进提供依据。方法依据住院病案首页数据填写规范(2016版),由专职的编码员按专科每月15%的比例随机抽取并进行住院病案首页质量的考核工作。将2019年1月1日-6月30日定义为MDT实施前期,2019年7月1日-12月31日定义为实施后期,分析对比2组住院病案首页平均得分、具体缺陷构成情况。运用SPSS19.0进行数据的统计分析,P<0.05为差异具有统计学意义。结果MDT实施后住院病案首页平均得分95.91±2.54,明显高于实施前92.94±4.34,且联系人、职业、地址、主要诊断、主要手术和操作等项目填写缺陷率较实施前均有不同程度的降低,差异具有统计学意义。结论MDT通过完善组织架构、加强人员培训、改进信息系统、建立奖惩机制、优化沟通渠道等一系列手段,全面构建联动工作机制,使多部门联合参与、共同监管,住院病案首页各项目填写错误率明显下降,真正实现住院病案首页内涵质量的持续改进。

Objectives To explore the application value of clinical multidisciplinary treatment in the quality management of the front page of i npati ent medi cal records,so as to provi de a basi s for the conti nuous improvement of the first page of inpatient medical records.Methods According to the inpatient medical record home data filling specifications(2016 version),by full-time coders according to the specialized monthly workload of 15%random selection and inpatient medical record home quality assessment work.F romJ anuary 1 st to J une 30 th of 2019 was defined as the early stage of MDT implementation,and From July 1 st to December 31 st of 2019 was defined as the later stage of MDT implementation.The average score and specific defect composition of the front page of medical records of the two groups were analyzed and compared.SPSS19.0 was used for statistical analysis of the data,and P<0.05 was considered as statistically significant.Results After the implementation of MDT,the average score on the first page of inpatient medical records(95.91±2.54)was significantly higher than that before the implementation(92.94±4.34),and the defect rate of the contact person,occupation,address,major diagnosis,major surgery and operation was significantly lower than that before the implementation.Conclusions MDT through perfecting the organizational structure,strengthen personnel training,improve the information system,establish rewards and punishment mrechanism;optimize the communication channels and a series of means,setting up mechanism of work comprehensively,make a rrulti-sectoral joint participation,mutual supervision,all items in hospital medical record front page to fill in error rate significantly decreased,achieve the continuous improvement of quality of hospital medical record front page content.However,it should be noted that the front page of hospital medical records MDT was still in the exploration stage,and there were still some problems in the application process,which needed to be further optimized and impraved in practice.