江苏省医院协会医院管理创新研究课题(JSYGY-1/2-2020-786)
目的 探讨多科室协作管理模式对提高住院病案首页质量的应用效果。方法 2020年4月起开始实施病案首页质量多学科协作管理模式，随机抽取2020年1月1日－2020年6月30日2999份住院病案首页作为实施前组，2021年1月1日－2021年6月30日2815份住院病案首页作为实施后组，对比分析两组病案首页数据质量管理与控制指标。结果 多科室协作管理模式实施后住院病案首页平均得分(98.47±2.24)分，明显高于实施前(96.81±3.36)分，实施后病案首页数据质量优秀率84.12%，明显高于实施前56.52%，且实施后的病案首页填报完整率、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、主要手术及操作选择正确率、手术及操作编码正确率较实施前均有不同程度的提高，差异具有统计学意义。结论 多科室协作管理模式可明显提高住院病案首页质量，值得推广使用。
Objective To explore the application effect of multi-department treatment mode in improving the quality of medical records homepage. Methods From April 2020, the multi-department treatment mode was implemented. 2999 front pages of medical records from January 1st, 2020 to June 30th, 2020 were randomly selected as the pre-implementation group and the other 2815 ones from January 1st, 2021 to June 30th, 2021 as the control group. The data quality management and control indexes of the two groups were compared and analyzed. Results The average score of medical records homepage was significantly higher than the control group (98.47±2.24 vs 96.81±3.36 ). The excellent rate of data quality of medical records homepage was significantly higher than the control group (84.12% vs 56.52%). After the implementation, the completion rate of the front sheet, the correct rate of main diagnosis selection, main diagnosis code, complete correct rate of other diagnosis, correct rate of other diagnosis codes, correct rate of main surgery and operation selection, the accuracy of operation and operation coding was improved to varying degrees compared with the control group, and the difference was statistically significant. Conclusion The multi-department treatment mode can significantly improve the quality of medical records homepage, which is worthy of popularization and use.