多学科协作管理模式提高住院病案首页数据质量

Research on Using Multi-disciplinary Team Model to improve the Quality of the Front Pages of Medical Records

目的分析多学科协作管理模式对提高住院病案首页质量的效果,探索住院病案首页质量持续改进方式。方法2020年4月起开始实施住院病案首页质量多学科协作管理模式,随机抽取2020年1月-3月、2021年1月-3月实施前后共2000份住院病案首页,按照《住院病案首页数据填写规范(2016版)》进行质量考核,对比分析实施前后两组住院病案首页数据质量管理与控制指标、主要错误项目填写变化情况。结果多学科协作管理模式实施后组住院病案首页平均得分明显高于实施前组,实施后组住院病案首页数据质量优秀率明显高于实施前组,且实施后组住院病案首页填写错误率较实施前组降低,差异有统计学意义。结论实施多学科协作管理模式对提高住院病案首页质量的效果显著,值得推广使用。

Objectives To analyze the effect of multi-disciplinary team model in the quality management of the front pages of inpatient medical records,so as to explore the methods of the continuous improvement of the quality in the front page of inpatient medical records.Method The MDT management mode has been implemented from April in 2020.According to the"Specification for data filling in the front pages of medical records(2016)",2000 front pages of inpatient medical records were randomly selected from clinical departments before and after the implementation for quality assessment between January 1st,2020 and march 31st,2021.The data quality management and control indexes of the front pages of inpatient medical records and main error items of the two groups before and after the implementation were compared and analyzed.Results After the implementation of MDT,the average score of the front pages was 98.31±2.38,significantly higher than the data after the implementation(96.75±3.14),the excellent rate of data quality was 82.0%,which was significantly higher than the data before the implementation(57.2%).The filling error rate of main diagnosis,other diagnoses,main surgery and operation,other surgery and operation,contact person,address,zip code on the front pages of medical records were decreased to varying degrees,the difference was statistically significant.Conclusions The implementation of MDT mode had a significant effect on improving the quality of the front pages of medical records,which was worthy of popularization and application.