PDCA循环法对提高病案首页数据质量及DRGs数据质量的应用

Application of PDCA Cycle Method to Improve the Data Quality of Medical Records First Page and DRGs Data Quality

目的研究PDCA循环法对提高病案首页数据质量的应用效果,以及对DRGs数据质量产生的影响。方法从2019年6月至2019年12月在我院出院的病案中抽取1000份作为本次研究的对照组,对照组未接受任何干预和培训。从2020年1月至2020年6月在我院出院的病案中选取1000份作为本次研究的观察组,予以专业培训和PDCA循环法干预。对比观察组与对照组的DRGs指标数据变化情况,同时比较两组的主要诊断选择缺陷率、其他诊断填写缺陷率、入院病情评估缺陷率、离院方式漏填率、有创操作漏填率以及主要疾病诊断编码错误缺陷率。结果观察组的DRGs总量和CMI均大于对照组,两组的DRGs总量和CMI比较存在显著差异(P<0.05);观察组的主要诊断选择缺陷率、其他诊断填写缺陷率、入院病情评估缺陷率、离院方式漏填率、有创操作漏填率以及主要疾病诊断编码错误缺陷率均显著低于对照组,P<0.05,存在显著差异。结论在病案首页培训工作中运用PDCA循环法可以大大提高病案首页数据质量,同时可提高DRGs数据质量,大大提高了病案首页的填报质量,降低缺陷的发生率,从而提高医疗质量管理水平,因此,值得进一步推广和应用。

Objective To study the application effect of PDCA cycle method on improving the data quality of the first page of medical records,as well as the effect on the data quality of DRGs.Methods From June 2019 to December 2019,1000 medical records discharged from our hospital were selected as the control group of this study,and the control group received no intervention or training.From January 2020 to June 2020,1000 medical records discharged from our hospital were selected as the observation group for this study,and professional training and PDCA cycle intervention were conducted.The change of DRGs index data between the observation group and the control group was compared.Meanwhile,the major diagnostic selection defect rate,other diagnosis filling rate,admission condition evaluation defect rate,discharge mode omission rate,invasive operation omission rate,and major disease diagnostic code error defect rate were also compared between the two groups.Results The total amount of DRGs and CMI in the observation group was higher than that in the control group,and there were significant differences between the two groups(P<0.05).In the observation group,the rate of major diagnosis selection defect,rate of other diagnosis filling,rate of admission condition evaluation defect,rate of discharge mode omission,rate of invasive operation omission and rate of major disease diagnostic code error were significantly lower than those in the control group,P<0.05,with significant differences.Conclusion In the training work of the first page of medical records,the application of PDCA cycle can greatly improve the data quality of the first page of medical records,and at the same time improve the DRGs data quality,greatly improve the filling quality of the first page of medical records,reduce the incidence of defects,and thus improve the level of medical quality management.Therefore,it is worth further promotion and application.