使用高值耗材病案的质量管理

Quality Management of Medical Records Using High Value Consumables

医用高值耗材管理是当前公立医院管理的热点和难点。某院开展高值耗材病案管理,从病案中提取耗材使用的信息,并对其进行专业评价,大大扭转了个别科室存在的乱用、滥用现象。首先通过宣传教育,让全院职工认识到在病案中记录高值耗材是法律法规的要求,是维护医患双方权益的需要。医院规定条形码、知情同意书、手术记录是耗材在病案中的主要记录形式,管理部门定期组织抽查病案,检查耗材记录存在的缺陷,结果与绩效考核挂钩。建立高值耗材点评制度,从病案中摘取适应症和耗材使用情况,对耗材的规范性和临床适宜性进行评价。通过对耗材使用的精准约束机制,有力地推动了耗材的合理使用,保障了疑难危重患者使用高值耗材不受影响的同时,很好地完成了上级下达的耗占比指标。

The management of medical high-value consumables is a hot and difficult point in the management of public hospitals.The hospital carries out the management of medical records and extracts the information on the use of consumables to perform professional evaluations,which greatly reverses the abuse of some departments.First of all,through education,the staff of the hospital realized that it is a requirement of laws and regulations to record high-value consumables in medical records,and it is the need to safeguard the rights and interests of both doctors and patients.The hospital stipulates that bar codes,informed consent,and surgical records are the main forms of records of consumables in medical records.The hospital regularly organizes random inspections of medical records,checks for defects in consumables records and the results are linked to performance appraisal.The hospital also established a high-value consumables review system by which to evaluate the normative and clinical suitability of consumables.Through the management of high-value consumable medical records,the hospital has formed a precise restraint mechanism for the use of consumables.