多学科协作模式在病案首页质量控制管理中的应用

Effect of multi-disciplinary treatment mode on quality control of the medical records homepage

目的应用多学科协作(Multi-disciplinary treatment,MDT)模式对病案首页质量控制进行管理,评价其应用效果。方法从广西某三甲医院首页填写质控系统中选取2019年1月1日—2020年12月31日收录的病案73223份,将2019年1月1日—12月31日收录的病案34644份归入此次研究的对照组,将2020年1月1日—12月31日收录的病案38579份归为此次研究的干预组。对照组的病案未实施MDT模式管理,干预组的病案接受MDT模式管理。分析对比两组的病案首页平均分、首页A类项目、各专科首页填写的变化情况。结果MDT干预组住院病案首页平均得分为(117.22±3.28)分,明显高于对照组的(116.36±3.68)分,差异有统计学意义(P<0.05)。且病案首页中A类项目主要诊断、主要手术操作、总费用等项目填写正确率较对照组均有不同程度的提高,差异具有统计学意义(P<0.05),专科首页填写正确率也大幅提高。结论在医院的病案质量管理工作中,使用MDT模式管理可明显提升病案首页数据正确率,具有较高的应用价值。

Objective To study the effect of Multi-Disciplinary Treatment(MDT)Mode on the quality control of medical records homepages.Methods A total of 73223 medical records collected from the quality control system of the hospitals in Guangxi from January 1,2019 to December 312020 were included in the study:34644 of them collected from January 1 to December 31,2019 as the control group and the other 38579 ones collected from January 1st to December 31st,2020 as the intervention group.The medical records of the control group were not treated based on the MDT mode,and those of the intervention group based on the MDT mode.The two groups were compared in terms of the average scores of the homepages,category A items on the homepage,and changes of the homepages by the clinical specialists.Results The average score on the homepage of the inpatient medical records in the intervention group was significantly higher than the control group(117.22±3.28 vs.116.36±3.68,P<0.05).In addition,the correct rate of the main category A items like main diagnosis,main surgical operations,and total cost on the front pages was significantly improved to varying degrees compared with the control group(P<0.05),and the correct rate of homepage writing was also improved to a great extent.Conclusion For the hospital′s medical record quality,the MDT mode can significantly improve the accuracy of the data on the homepages of the medical records.It is of high value for practical use.