PDCA循环对主要诊断编码质量的影响

The Effect of PDCA Cycle on the Quality of Main Diagnostic Coding

目的分析应用PDCA循环管理住院病案首页前后主要诊断编码正确率,探讨运用PDCA循环对于提高主要诊断编码质量的作用。方法从某院病案管理系统随机抽取2020年4月1日-2020年6月30日出院病案共600份作为干预前组,由医务处牵头,由4名医师及4名编码员组成CQI小组,对住院病案首页填报实施PDCA循环管理。随机抽取实施管理后的2021年4月1日-2021年6月30日出院病案600份作为干预后组,由CQI小组对干预前组和干预后组的住院病案首页填报情况进行质量监控,比较干预前后主要诊断编码的正确率。结果干预后组主要编码正确率为85.50%,高于干预前组的70.00%,P<0.05,差异有统计学意义。干预后组医师主要诊断选择正确病案数525份、编码员主要诊断编码正确病案数558份、系统传送正确病案数600份均高于干预前组的429份、549份、588份。各项差异均具有统计学意义。结论针对住院病案首页中主要诊断编码实施PDCA,可有效提升主要诊断编码正确率,增强编码员的责任意识,促进医师规范填写主要诊断,从而有力地改善住院病案首页质量。

Objectives The accuracy of main diagnostic codes before and after PDCA cycle was analyzed,and the effect of PDCA cycle on improving the quality of main diagnostic codes was discussed.Methods A total of 600hospital medical records from April 1st,2020 to June 30th,2020 were randomly selected from the medical record management system of a hospital as the pre-intervention group.The CQI group,led by the medical department and composed of 4 physicians and 4 coders,implemented PDCA cycle management on the home page filling of inpatient medical records.A total of 600 hospital medical records from April 1st,2021 to June 30th,2021 after the implementation of the management were randomly selected as the post-intervention group.The CQI group carried out quality control on the front page filling of inpatient medical records in the pre-intervention group and the post-intervention group,and compared the accuracy of main diagnostic codes before and after the intervention.Results The correct rate of main coding in the post intervention group was 85.50%,which was higher than 70.00%in the pre intervention group(P<0.05).The number of correct medical records selected by doctors,558 by coders and 600 by system transmission in the post intervention group were higher than 429,549 and 588 in the pre intervention group.The differences were statistically significant.Conclusions The implementation of PDCA for the main diagnostic codes in the front page of medical records could effectively improve the accuracy of main diagnostic codes,enhance the coder’s sense of responsibility,and promote doctors to fill in the main diagnosis in a standardized manner,so as to effectively improve the quality of the front page of medical records.