该文回顾性分析了病理诊断编码缺失现状与原因,发现病理结果晚归与病案归档率相互矛盾,医生与编码员“回头看”意识淡薄,“医-编”存在信息壁垒等导致病理诊断编码缺失率高,疾病诊断编码不规范导致DRG(Diagnosis Related Groups,按疾病...该文回顾性分析了病理诊断编码缺失现状与原因,发现病理结果晚归与病案归档率相互矛盾,医生与编码员“回头看”意识淡薄,“医-编”存在信息壁垒等导致病理诊断编码缺失率高,疾病诊断编码不规范导致DRG(Diagnosis Related Groups,按疾病诊断相关分组)不入组或入组后病种综合指数(Case Mix Index,CMI)低。该文探索通过多平台发布病理阳性报告并开放多角色权限、编码员阶段性填补病理诊断编码、开展多科室多层次质控等多学科协作诊疗(MultiDisciplinary Team,MDT)模式,对病案首页病理诊断编码进行查缺补漏等措施,结果显示病案首页数据的完整性、准确性、规范性、及时性、真实性均有所提高,相关科室业务互动增强,为精细化管理奠定了基础。建议今后优化升级电子病历系统,整合病历资料,开发智能编码,节省“医-编”时间,结合上级检查开展专项专题质控,持续改进。展开更多
目的 探讨应用多学科诊疗联合案例教学法进行神经外科重症监护规范化培训的教学效果。方法 选取2023年6月至2024年6月期间在南通市第一人民医院神经外科重症监护室进行规范化培训的68名学员,分别随机分配为对照组与试验组,其中对照组采...目的 探讨应用多学科诊疗联合案例教学法进行神经外科重症监护规范化培训的教学效果。方法 选取2023年6月至2024年6月期间在南通市第一人民医院神经外科重症监护室进行规范化培训的68名学员,分别随机分配为对照组与试验组,其中对照组采用传统的以讲授为主(LBL)的教学模式,而试验组则采用多学科团队(MDT)结合案例教学法(CBL)的方式。通过出科考试评估,包括基础理论、影像读片、病理诊断、治疗方式和实操技能五个方面。此外,还设计了调查问卷,以评估学员在接受教学后对于自己提高学习兴趣、培养自主学习能力、加深对理论知识的理解、培养分析问题的能力、锻炼交流和表达能力和提高实践能力等方面的认可程度,以及对教学的满意度进行比较和分析。结果 在理论成绩方面,两组学员未见明显差异,而在影像读片等其他出科考试、教学效果认可度及教学满意度方面,试验组相较于对照组有较为明显的提高,差异均具有统计学意义(P Objective: To explore the teaching effect of applying multidisciplinary diagnosis and treatment combined with case-based teaching method in the standardized training of neurosurgical intensive care residents. Methods: Sixty-eight trainees who underwent standardized training in the Neurosurgery Intensive Care Unit of Nantong First People’s Hospital from June 2023 to June 2024 were selected and randomly divided into the control group and the experimental group. The control group adopted the traditional lecture-based (LBL) teaching mode, while the experimental group adopted the multidisciplinary team (MDT) combined with case-based learning method (CBL). The assessment was conducted through the graduation examination, covering five aspects: basic theory, image reading, pathological diagnosis, treatment methods, and practical skills. In addition, a questionnaire was designed to evaluate the trainees’ recognition of their improvement in learning interest, cultivation of autonomous learning ability, deepening of understanding of theoretical knowledge, training of problem-solving ability, exercise of communication and expression skills, and improvement of practical ability after receiving the teaching, as well as the satisfaction with the teaching. Comparisons and analyses were made to compare and analyze the results. Results: In terms of theoretical scores, there was no significant difference between the two groups of trainees. However, in other post-graduation examinations such as image reading, teaching effectiveness recognition, and teaching satisfaction, the experimental group showed a more significant improvement compared to the control group, and the differences were statistically significant (P < 0.05). Conclusion: The MDT combined with CBL teaching model has significantly enhanced the standardized training effect of neurosurgery interns in the intensive care unit. This model not only effectively boosts the learning interest of trainees but also cultivates their ability to analyze problems and effectively improves their comprehensive clinical qualities.展开更多
文摘目的 探讨应用多学科诊疗联合案例教学法进行神经外科重症监护规范化培训的教学效果。方法 选取2023年6月至2024年6月期间在南通市第一人民医院神经外科重症监护室进行规范化培训的68名学员,分别随机分配为对照组与试验组,其中对照组采用传统的以讲授为主(LBL)的教学模式,而试验组则采用多学科团队(MDT)结合案例教学法(CBL)的方式。通过出科考试评估,包括基础理论、影像读片、病理诊断、治疗方式和实操技能五个方面。此外,还设计了调查问卷,以评估学员在接受教学后对于自己提高学习兴趣、培养自主学习能力、加深对理论知识的理解、培养分析问题的能力、锻炼交流和表达能力和提高实践能力等方面的认可程度,以及对教学的满意度进行比较和分析。结果 在理论成绩方面,两组学员未见明显差异,而在影像读片等其他出科考试、教学效果认可度及教学满意度方面,试验组相较于对照组有较为明显的提高,差异均具有统计学意义(P Objective: To explore the teaching effect of applying multidisciplinary diagnosis and treatment combined with case-based teaching method in the standardized training of neurosurgical intensive care residents. Methods: Sixty-eight trainees who underwent standardized training in the Neurosurgery Intensive Care Unit of Nantong First People’s Hospital from June 2023 to June 2024 were selected and randomly divided into the control group and the experimental group. The control group adopted the traditional lecture-based (LBL) teaching mode, while the experimental group adopted the multidisciplinary team (MDT) combined with case-based learning method (CBL). The assessment was conducted through the graduation examination, covering five aspects: basic theory, image reading, pathological diagnosis, treatment methods, and practical skills. In addition, a questionnaire was designed to evaluate the trainees’ recognition of their improvement in learning interest, cultivation of autonomous learning ability, deepening of understanding of theoretical knowledge, training of problem-solving ability, exercise of communication and expression skills, and improvement of practical ability after receiving the teaching, as well as the satisfaction with the teaching. Comparisons and analyses were made to compare and analyze the results. Results: In terms of theoretical scores, there was no significant difference between the two groups of trainees. However, in other post-graduation examinations such as image reading, teaching effectiveness recognition, and teaching satisfaction, the experimental group showed a more significant improvement compared to the control group, and the differences were statistically significant (P < 0.05). Conclusion: The MDT combined with CBL teaching model has significantly enhanced the standardized training effect of neurosurgery interns in the intensive care unit. This model not only effectively boosts the learning interest of trainees but also cultivates their ability to analyze problems and effectively improves their comprehensive clinical qualities.
