[1]李 文.PDCA循环改进对提高胸科医院病案首页主要诊断正确率的影响[J].医学信息,2023,36(15):164-166,174.[doi:10.3969/j.issn.1006-1959.2023.15.035]
　LI Wen.Effect of PDCA Circulation Improvement on Improving the Main Diagnostic Accuracy of the Front page of Medical Records in Chest Hospital[J].Journal of Medical Information,2023,36(15):164-166,174.[doi:10.3969/j.issn.1006-1959.2023.15.035]
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PDCA循环改进对提高胸科医院病案首页主要诊断正确率的影响()
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医学信息[ISSN:1006-1959/CN:61-1278/R]

卷:
36卷
期数:
2023年15期
页码:
164-166,174
栏目:
护理研究
出版日期:
2023-08-01

文章信息/Info

Title:
Effect of PDCA Circulation Improvement on Improving the Main Diagnostic Accuracy of the Front page of Medical Records in Chest Hospital
文章编号:
1006-1959（2023）15-0164-04
作者:
李 文
（天津市胸科医院病案质检科，天津 300222）
Author(s):
LI Wen
(Department of Medical Record Quality Inspection,Tianjin Chest Hospital,Tianjin 300222,China)
关键词:
胸科医院; 病案首页; 主要诊断
Keywords:
Chest hospital; Front page of medical record; Main diagnosis
分类号:
R197.32
DOI:
10.3969/j.issn.1006-1959.2023.15.035
文献标志码:
A
摘要:
目的 研究PDCA循环改进对提高胸科医院病案首页主要诊断正确率的影响。方法 将2022年7月-12月天津市胸科医院实施PDCA循环改进管理的116份病案首页设为观察组，将2022年1月-6月未实施PDCA循环改进管理的116份病案设为对照组。比较两组病案首页主要诊断正确率、病案归档率、病历分级情况、病案填写质量以及病案管理水平。结果 观察组病案首页主要诊断、手术主要操作正确率均高于对照组（P＜0.05）；观察组病案2日归档率、3日归档率均高于对照组，7日归档率低于对照组（P＜0.05）；观察组甲级病历占比高于对照组，乙级、丙级病历占比低于对照组（P＜0.05）；观察组各维度病案首页填写质量评分高于对照组（P＜0.05）；观察组病案首页管理评分高于对照组（P＜0.05）。结论 PDCA循环改进可提高胸科医院病案首页主要诊断正确率，促进病案快速归档，提高病历分级和病案填写质量水平，进一步提升医院整体病案管理水平，为医院的可持续发展提供有利的条件。
Abstract:
Objective To study the effect of PDCA cycle improvement on improving the main diagnostic accuracy of the first page of medical records in chest hospital.Methods The first page of 116 medical records were implemented by PDCA cycle improvement management in Tianjin Chest Hospital from July to December 2022 was set as the observation group, and 116 medical records were not implemented by PDCA cycle improvement management from January to June 2022 were set as the control group. The main diagnostic accuracy, medical record filing rate, medical record classification, medical record filling quality and medical record management level of the two groups were compared.Results The correct rates of main diagnosis and operation on the front page of medical records in the observation group were higher than those in the control group (P<0.05). The 2-day archiving rate and 3-day archiving rate of medical records in the observation group were higher than those in the control group, and the 7-day archiving rate was lower than that in the control group (P<0.05). The proportion of grade A medical records in the observation group was higher than that in the control group, and the proportion of grade B and grade C medical records was lower than that in the control group (P<0.05). The quality score of filling in the front page of medical records in each dimension of the observation group was higher than that of the control group (P<0.05). The management score of the first page of medical records in the observation group was higher than that in the control group (P<0.05).Conclusion PDCA cycle improvement can improve the main diagnostic accuracy of the first page of medical records in chest hospital, promote the rapid filing of medical records, improve the classification of medical records and the quality of medical records, further improve the overall management level of medical records in hospitals, and provide favorable conditions for the sustainable development of hospitals.

参考文献/References:

[1]李小娟,刘娅,魏华丽,等.利用品管圈管理工具改善住院病案首页填写质量[J].中国病案,2020,21(10):11-14.[2]郭果桃.网络直报下的病案首页质量管理分析[J].基层医学论坛,2019,23(8):1146-1147.[3]孙晋科,王晓盈,姜国成.基于无纸化病案室实现病案全生命周期闭环管理[J].中国数字医学,2018,13(6):110-112.[4]成卓,明捷,肖俊杰,等.DRGs背景下住院病案首页质量控制应用效果分析及改进措施[J].重庆医学,2022,51(20):3587-3590.[5]曾俊群,李慧江,马艳良,等.住院医师DRGs知识培训对提高其病案诊断与手术操作填报正确率的研究[J].医院管理论坛,2019,36(2):19-22.[6]许斌,赵文超,吕圣兰,等.住院病案首页入院病情填写质量分析及改进对策[J].江苏卫生事业管理,2019,30(3):325-327.[7]李清香,陈海燕,李松兴.PDCA循环管理在病案首页质量监控的应用[J].中国处方药,2019,17(4):34-36.[8]张丽敏,杨建玲,王丽君,等.基于DRGs的病案首页质量分析[J].中国卫生质量管理,2019,26(1):33-35.[9]李雪云,唐瑞璠,戴春霞,等.品管圈在提高病案首页数据质量中的应用[J].齐齐哈尔医学院学报,2022,43(5):497-501.[10]梁景星,赵跃宝,黄勇,等.基于DRGs付款下高倍率病例的病 案首页诊断与手术操作填写和编码缺陷分析[J].中国医院统计,2019,26(4):307-310.[11]张慧利,张连军,周云,等.外科病案首页诊断与手术操作数据质量分析[J].现代医院管理,2018,16(6):30-32.[12]何美玲,曾令霞.住院病案首页主要诊断及主要手术操作编码持续性质控的效果分析[J].中国医院统计,2022,29(5):362-366,372.[13]吴文健,孙晖,刘颖,等.利用信息技术提高病案首页的编码准确率[J].江苏卫生事业管理,2020,31(1):57-58,66.[14]陈海云,陈皇宇,戚苗苗,等.全面质量管理在提高医保病案编码准确率中的应用[J].东南国防医药,2018,20(1):93-97.[15]杨燕媚.病案归档管理对疾病诊断相关分组及病案首页质量的影响[J].中国医院统计,2019,26(3):239-240,封3.[16]谢金明.加强病案首页质量控制前后对提高诊断填写正确率的积极作用[J].中国卫生标准管理,2021,12(23):4-7.[17]李小丹,梁嘉诚,邝倩仪,等.病案首页ICD编码的准确率对DRGs付费影响[J].广州医药,2022,53(6):96-99,132.[18]何凯平,刘涛,张柔玲,等.PDCA循环在提升病案首页信息质量的应用[J].现代医院,2019,19(1):48-50. [19]周春梅,吴志军,朱卫华.质量提高月活动对病案首页填写质量影响的调查[J].交通医学,2021,35(6):655-657.

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更新日期/Last Update: 1900-01-01