PDCA循环法对住院病案首页信息质量的效果评价

Evaluation of the Effect of PDCA Cycle Method on the Information Quality of the Front Page of Inpatient Medical Records

目的运用PDCA循环法改进住院病案首页信息质量,提高医疗信息统计数据的准确性。方法选取2020年与2022年1月1日-4月30日的出院病案20853份作为研究对象。将2020年1月1日-2020年4月30日PDCA循环管理前的10699份出院病案作为对照组,2022年1月1日-4月30日循环管理后的10154份出院病案作为研究组,根据住院病案首页填写规范与质控要求对住院病案首页质量缺陷、医师住院病案首页诊断及编码员编码合格情况进行统计分析。结果PDCA循环管理后住院病案首页信息总体缺陷率由49.33%显著下降到19.97%,其中基本信息缺陷率、住院过程信息缺陷率、诊疗信息缺陷率、手术与操作填写缺陷率均下降;医师住院病案首页诊断不合格率由12.82%降到6.84%,其中医师诊断填写及手术操作填写不规范或错误发生率、漏填缺陷率均下降;编码员编码不合格率由9.05%降到3.68%,其中诊断编码及手术操作编码不规范或错误发生率、漏填缺陷率均下降。结论运用PDCA循环管理模式可以提高住院病案首页的信息质量,有利于DIP大数据的正确分组,值得推广应用。

Objectives This study aims to use the PDCA cycle method to improve the information quality of the front page of inpatient medical records and improve the accuracy of medical information statistics.Methods A total of 20,853 medical discharge records from January 1,2020 to April 30,2022 were selected as the study subjects.10699 discharged medical records before PDCA cycle management from January 1 to April 30 in 2020 were used as the control group,and 10154 discharged medical records after the cycle management from January 1 to April 30 in 2022 were used as the research group.According to the filling specification and quality control requirements of the front page of inpatient medical records,the quality defects of the front page of inpatient medical records,the diagnosis of the front page of inpatient medical records by doctors,and the qualification of the front page of inpatient medical records coded by coders were statistically analyzed.Results After the application of PDCA cycle management,the overall defect rate of information on the front page of hospitalization records decreased from 49.33%to 19.97%,among which the defect rates of basic information,hospitalization process information,the defect rate of diagnosis and treatment information,and defect rate of operation and operation filling all decreased.The unqualified diagnosis rate on the front page of physicians’inpatient medical records has dropped from 12.82%to 6.84%,among which the non-standard or wrong and non-compliance rate of physicians’diagnosis filling and surgical operation filling,and the rate of missing filling defects had all decreased.The unqualified rate of coders coding the front page of inpatient medical records dropped from 9.05%to 3.68%,among which the rates of non-standard diagnostic codes and surgical operation codes,or errors and unqualified rates,and the rate of missed filling defects had all decreased.Conclusions The application of PDCA cycle management mode can improve the information quality on the front page of the medical records,which is conducive to the correct grouping of DIP big data and is worth popularizing and applying.