101例全院大会诊病案分析

Analysis of 101 Medical Records of Hospital-Wide Consultation

目的通过对某院大会诊资料的分析,了解会诊制度的执行及运转情况,探索会诊工作中存在的不足,为提高医疗水平和组建多学科合作团队提供科学依据。方法收集2013年-2015年间安徽省某三甲医院101例患者全院大会诊资料,从患者转归及科室分布等方面对数据进行分析。结果最终好转出院49人(48.51%),死亡8人(7.92%),死亡率逐年下降;ICU提出会诊申请最多共16例,感染科被邀请参加会诊次数最多共39例,被邀请参加会诊的副主任医师及主任医师占85%以上。结论应进一步加强各学科间的协作,提高会诊质量,利用信息化手段,借助互联网技术搭建会诊平台,从而提升全院大会诊精细化管理水平。?

Objective By analyzing the data of consultations,we realize the execution and operation of consultation system,and explore the defects in the hospital-wide consultation,in order to provide the scientific basis to improve medical treatment and multi-disciplinary team.Methods We collected the information of the hospital-wide consultation from a hospital of Class A in Anhui province during 2013 to 2015.There were 101 records in three years.Data were analyzed from aspects such as patient outcomes and department distributions.Results Eventually 49 patients improved（48.51%） and 8 patients were dead（7.92%）,then the mortality rate decreased year by year;ICU proposed the consultation cases up to a total of 16,while infections department was invited most frequently to a total of 39.The associate chief physician and chief physicians invited to the consultations were more than 85%.Conclusions It needs to strengthen the cooperation of the departments and improve the quality of consultation.Use the internet technology to establish the consultation platform,in order to promote the level of fine management for hospital-wide consultation.