摘要
目的 研究多学科协作管理对住院病案首页填写质量的影响,为住院病案首页填写管理方案的完善提供科学参考。方法 研究对象随机选取某院2023年1月1日—2024年12月31日住院病案合计4133份,以MDT管理方案应用时间即2023年7月1日作为分组节点,分为对照组(2012份)及研究组(2111份),观察2组住院病案首页管理质量评分、质量控制指标、住院病案首页填写质控评分。计量资料先进行正态分布检验,符合正态分布资料采用独立样本t检验,不符合正态分布资料采用秩和检验,计数资料采用χ^(2)检验。结果 研究组书写质量、规范、水平、真实4个维度评分及总分均高于对照组(98.14±4.85比96.08±4.73)分、(97.24±4.35比95.11±4.02)分、(95.76±4.32比94.53±4.22)分、(96.37±4.21比95.08±4.15)分,P<0.001;研究组住院病案首页优秀率、填报完整率、主要诊断选择正确率、主要诊断编码正确率、其他诊断填写完整正确率、其他诊断编码正确率、主要手术与操作选择正确率、手术与操作编码正确率高于对照组,分别为94.69%比92.28%、94.84%比92.53%、93.98%比91.19%、95.26%比92.58%、95.22%比92.73%、95.93%比94.16%、95.59%比93.72%、95.07%比92.83%,均P<0.01;研究组各科室住院病案首页填写自控评分均高于对照组,P<0.001。结论 多学科协作管理有助于提高住院病案首页的书写质量和准确率,规范医疗行为,因而具有广泛的推广价值。
Objectives This study aims to investigate the effect of multidisciplinary team(MDT)management on the quality of filling in the front page of inpatient medical records,and to provide a scientific reference for the improvement of the management scheme of filling in the front page of inpatient medical records.Methods A total of 4,133 medical records of a hospital from January 1,2023 to December 31,2024 were randomly selected.Taking the application time of MDT management plan(July 1,2023)as the group node,the patients were divided into the control group(2012 cases)and the study group(2111 cases).The quality scores of medical record front page management,quality control indicators,and quality control scores of inpatient medical record front page filling were observed in the two groups.The measurement data were first tested for normal distribution.The independent sample t-test was used for the data that met the normal distribution,the rank sum test was used for the data that did not meet the normal distribution,and the χ^(2) test was used for the count data.Results The scores of four dimensions of writing quality,specification,level and truth and the total score of the study group were higher than those of the control group(98.14±4.85 vs 96.08±4.73,97.24±4.35 vs 95.11±4.02,95.76±4.32 vs 94.53±4.22,96.37±4.21 vs 95.08±4.15;P<0.001).The excellent rate of medical record homepage,the complete rate of medical record front page filling,the correct rate of main diagnosis selection,the correct rate of main diagnosis coding,the complete rate of other diagnosis filling,the correct rate of other diagnosis coding,the correct rate of major operation and operation selection,the correct rate of operation and operation coding in the study group were higher than those in the control group(94.69 vs 92.28%,94.84 vs 92.53%,93.98 vs 91.19%,95.26 vs 92.58%,95.22 vs 92.73%,95.93 vs 94.16%,95.59 vs 93.72%,95.07 vs 92.83%;P<0.01).The self-control scores of flling in the front page of inpatient medical records in the study group were higher than those in the control group(P<0.001).Conclusions The Multidisciplinary cooperative management is helpful to improve the quality and accuracy of writing the first page of inpatient medical records and standardize medical behavior,which has a wide range of promotional value.
作者
史永兴
郝光
崔醒儿
王忠冉
Shi Yongxing;Hao Guang;Cui Xinger;Wang Zhongran(Medical Record Office,The First Affiliated Hospital of Hebei North University,Zhangjiakou 075000,Hehei Province,China)
出处
《中国病案》
2025年第9期13-16,共4页
Chinese Medical Record
关键词
多学科协作
病案管理
住院病案首页
病案质量
Multidisciplinary collaboration
Medical record management
Medical record front page
Medical record quality
