运用PDCA循环提高ICD-10编码准确率  

To Improve the Accuracy of ICD-10 Coding with the Application of PDCA Cycle

作　　者：关曼璐 虎翼[2] 杜永强 马娟 李颖 王金莲 方浩 Guan Manlu,Hu Yi,Du Yongqiang,Ma Juan,Li Ying,Wang Jinlian,Fang Hao(The Cardiovascular and Cerebrovascular Disease Hospital of Ningxia General Medical University, Yinchuan 750011, Chin)

机构地区：[1]宁医大总院心脑血管病医院,银川市750011 [2]宁夏医科大学总医院,银川市750004

出　　处：《中国病案》2018年第5期26-29,共4页Chinese Medical Record

摘　　要：目的通过使用PDCA循环的管理办法提高病案ICD-10编码的准确率。方法某三级甲等医院病案统计室成立质量持续改进CQI小组,遵循PDCA循环4个阶段、8个步骤的原则实施PDCA循环管理,随机抽取2016年8月-2016年10月每月各500份病案,比较运用PDCA循环法前后的ICD-10编码准确率。结果出院病案ICD-10编码准确率明显提高,从实施前的75.4%提升至86.4%。实施过程中准确率呈现逐步上升的趋势,达到预定的目标值,编码准确率比较差异有统计学意义(P<0.01)。结论运用PDCA循环法能够有效提高ICD-10编码准确率,增强编码员的责任意识,提高医师书写疾病诊断准确性,加强了病案统计室管理水平。Objective To improve the accuracy of ICD-10 with the application of PDCA circulation management method. Methods Form a CQI group, obey the four stages of PDCA and eight steps to enhance the accuracy ICD-10.During the three months activity of the theme of enhancing the accuracy of ICD-10, ask question, analyze cause, set aim, work out and carry out a plan, check results and summarize it. Practice the next PDCA and compare the accuracy of ICD-10. Result There was an obvious advancement of accuracy of ICD-10 in discharged medical records. The accurate rate increased from 75.4% during investigation to 86.4% after three months. The rising of accuracy would get the expectation. Conclusion The application of PDCA would obviously enhance the accuracy of ICD-10. We should pay attention to the responsibility and advance the accuracy of diagnosis and administration ability of medical record department.

关 键 词：PDCA ICD-10 编码 准确率 

分 类 号：R197.323[医药卫生—卫生事业管理]