摘要
目的 研究PDCA循环法对提升医院出院病案质量及DRG相关数据质量应用效果。方法 以2022年1月作为研究对照阶段,将某医院该月内科、外科、妇产科、儿科、感染性疾病科出院的全部6182份病案资料设为对照组,同年2至12月作为PDCA循环法研究实施阶段,将上述科室同年12月出院的全部3778份病案资料设为观察组。对比两组的出院病案缺陷率、病案首页缺陷率、主要诊断编码选择正确率、CMI指标数据变化情况。结果 住院病案整体缺陷率由38.97%下降到38.62%(p=0.728),病案首页缺陷率由17.53%下降到15.25%(p=0.003),主要诊断选择正确率整体由89.37%上升到96.57%(p=0.786),观察组CMI为1.528高于对照组1.445(p=0.033)。结论 在病案质量管理工作中运用PDCA循环法可以有效提高病案首页数据质量与DRG相关指标数据质量。
Objective To study the application effect of PDCA cycle method in improving the quality of hospital discharge medical records and DRG related data.Methods January 2022 was used as the control phase of the study,and all 6182 case files discharged from the departments of internal medicine,surgery,obstetrics and gynecology,pediatrics,and infectious diseases of a certain hospital in that month were set as the control group,and all 3778 case files discharged from the above departments in December of the same year were set as the observation group during the implementation phase of the PDCA cycle method from February to December of the same year.The two groups were compared in terms of the defect rate of discharge medical records,the defect rate of medical record first page,the correct rate of main diagnosis code selection,and the change of CMI index data.Results The overall defect rate of inpatient medical records decreased from 38.97% to 38.62%(p=0.728),the defect rate of medical record first page decreased from 17.53% to 15.25%(p=0.003),and the accuracy rate of primary diagnosis increased from 89.37% to 96.57%(p=0.786).The CMI of the observation group was 1.528,which was higher than 1.445 of the control group(p=0.033).Conclusion The application of PDCA cycle method in medical record quality management can effectively improve the data quality of the first page of medical records and DRG related indicators.
作者
师雯琦
邓星
张其先
SHI Wen-qi;DENG Xing;ZHANG Qi-xian(The Third Affiliated Hospital of Sun Yat-sen University)
出处
《医院管理论坛》
2025年第2期84-87,共4页
Hospital Management Forum
基金
中山大学附属第三医院医院管理科研基金面上项目,编号:2021GLMS03。
关键词
病案首页
疾病诊断相关分组
数据质量
The first page of medical records
Diagnosis related groups
Data quality
作者简介
师雯琦,Email:zhangqx5@mail.sysu.edu.cn;通讯作者:张其先。
