PDCA循环法住院病案首页培训对DRGs数据的影响

The Influence of PDCA Cycle on the DRGs Data by the First Page Training of Hospital Medical Records

目的运用PDCA循环法进行病案首页填写的培训对提高病案首页数据质量以及DRGs数据质量的影响。方法通过分析首页DRGs数据,制定PDCA循环、通过不断改善首页填写质量提高DRGs数据质量,将培训开始前的2018年与进行培训后2019的DRGs数据分别选取有手术操作的科室和没有手术操作的科室,分析培训前后数据质量的变化情况。结果手术科室和非手术科室的DRGs总量、CMI值、组数、入组病例数在干预后与干预前相比,均有不同幅度提高(P<0.001),其中非手术科室DRGs总量提高4.96%,CMI值提高2.47%,DRGs组数提高5.35%,入组病例数提高9.16%;手术科室DRGs总量提高17.46%,CMI值提高3.99%,DRGs组数提高10.90%,入组病例数提高18.13%。结论运用PDCA循环法进行病案首页填写的培训对于提高病案首页数据质量、DRGs数据质量是一种行之有效的方法,临床编码员应定期到科室培训。

Objective To explore the effect of PDCA cycle method on improving the data quality of medical records and DRGs.Methods For looking for reasons of the low quality of medical record home page encoding,setting way to improve medical record home page,putting on a regular lecture for clinical departments each month,DRGs data review analysis,discussing,writing specification coded entries according to the disease,the DRGs data of 2018 before the training and 2019 after the training were selected from surgical departments and non-surgical departments,and the changes of data quality before and after the training were analyzed.Results Both the surgical department and non-surgical departments had statistically significant difference in DRGs,CMI value,group number,the total number of cases between before and after intervention.For non-surgical departments,the DRGs volume increased by 4.96%,the CMI value increased by2.47%,the number of sets of DRGs increased by 5.35%,the number of enrolled cases increased by 9.16%.For Surgical departments,DRGs increased by 17.46%,the CMI value increased by3.99%,the number of sets of DRGs increased by10.90%,the number of enrolled cases increased by 18.13%.Conclusions PDCA cycle method is an effective method to improve the quality of data on the first page of medical records and the quality of DRGs data.Clinical coders should go to the department for regular training.