基于多学科协作的管理模式对住院病案首页质量的影响
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许昌市妇幼保健院

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The influence of a management model based on multidisciplinary collaboration on the quality of the first page of inpatient medical records
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    摘要:

    目的:探讨基于多学科协作的管理模式对住院病案首页质量的影响。方法:抽取2023年4月至2024年4月期间于本院实施常规管理的750份病历作为对照组;抽取2024年5月至2025年5月期间实施基于多学科协作的管理模式的750份病历作为实验组。依据《住院病案首页治疗填写规范(2016)》等对病案首页进行质量评估。分析比较实施前后首页质量、主要质控项目错误情况,并分析编码错误构成比。结果:实验组的首页完整性显著高于对照组,编码问题占比、非编码问题占比均显著低于对照组(P<0.05)。实验组的B类、C类、D类项目的错误率均显著低于对照组(P<0.05);两组的A类项目错误率无显著差异(P>0.05)。实验组的前5类错误编码主要分布在合并症编码缺失或混淆、分娩结局分类错误、肿瘤编码笼统化、新生儿疾病分类偏差、先天异常编码混淆。对照组前5类错误编码主要分布在合并症编码缺失或混淆、先天异常编码混淆、分娩结局分类错误、肿瘤编码笼统化、慢性病遗漏。结论:基于多学科协作的管理模式能提高住院病案首页质量。

    Abstract:

    Objective: To explore the impact of a management model based on multidisciplinary collaboration on the quality of the first page of inpatient medical records. Method: 750 medical records that were subject to routine management in our hospital from April 2023 to April 2024 were selected as the control group. 750 medical records that implemented the management model based on multidisciplinary collaboration from May 2024 to May 2025 were selected as the experimental group. The quality of the first page of inpatient medical records was evaluated in accordance with the "Norms for Filling in Treatment on the First Page of Inpatient Medical Records (2016)" and other relevant regulations. The quality of the homepage before and after implementation, the error situations of the main quality control items, and the composition ratio of coding errors were analyzed and compared. Result: The completeness of the homepage in the experimental group was significantly higher than that in the control group, and the proportions of coding problems and non-coding problems were significantly lower than those in the control group (P < 0.05). The error rates of Class B, Class C and Class D items in the experimental group were significantly lower than those in the control group (P < 0.05). There was no significant difference in the error rate of Class A items between the two groups (P > 0.05). The top five types of incorrect codes in the experimental group were mainly distributed in the absence or confusion of codes for comorbidities, incorrect classification of delivery outcomes, generalization of tumor codes, deviation in classification of neonatal diseases, and confusion of codes for congenital abnormalities. The top five types of incorrect codes in the control group were mainly distributed in the absence or confusion of codes for comorbidities, confusion of codes for congenital abnormalities, incorrect classification of delivery outcomes, generalization of tumor codes, and omission of chronic diseases. Conclusion: The management model based on multidisciplinary collaboration can improve the quality of the first page of inpatient medical records.

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王松伟.基于多学科协作的管理模式对住院病案首页质量的影响[J].四川生理科学杂志,2026,48(9):

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  • 收稿日期:2025-08-01
  • 最后修改日期:2025-09-17
  • 录用日期:2025-10-27
  • 在线发布日期: 2026-08-27
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