品管圈在提高主要诊断ICD编码正确率中的应用  

Application of Quality Control Circle in Improving the Accuracy of ICD Coding of Medical Records

作　　者：肖鹏磊 滕俊玲[1] 许丹 高燕飞 李娅 刘宁娟[1] Xiao Penglei;Teng Junling;Xu Dan;Gao Yanfei;Li Ya;Liu Ningjuan(Department of Medical Record,He’nan Provincial People’s Hospital,Zhengzhou University People’s Hospital,Henan University People’s Hospital,Zhengzhou 450003,He’nan Province,China;不详)

机构地区：[1]河南省人民医院病案科,河南省郑州市450003

出　　处：《中国病案》2021年第8期5-8,共4页Chinese Medical Record

摘　　要：目的通过应用品管圈工具探索提高某三甲医院某外科住院病案首页主要诊断ICD编码正确率的方法。方法病案科成立品管小组,对该院某外科应用品管圈工具前2018年7月1日-2018年7月14日出院的399份住院病案首页,以及应用品管圈工具后2018年11月1日-2018年11月14日出院的436份住院病案首页进行主要诊断疾病分类编码的核对、检查,然后汇总进行描述性统计分析。针对主要诊断编码错误率高的现象,从人员、环境等多个维度进行分析,根据找出的原因制定对策并执行。结果实施一系列改进措施后,临床医师的书写质量、编码员的编码质量和电子病历系统的管理水平均有所改善,某外科住院病案首页主要诊断ICD编码正确率从86.97%提高到94.30%;同时,全体圈员的品管能力也有所提升。结论应用品管圈工具能有效提高某外科住院病案首页主要诊断ICD编码正确率,通品管圈工具可建立有效的闭环管理体系,使住院病案首页流通的每个环节都能得到控制,后期应持续实施。Objective To improve the ICD coding accuracy of primary diagnosis of medical records of a third-class hospital by using quality control circle.Methods The quality control circle was organized in the Department of Medical Records in a third grade hospital.Total of 399 medical records discharged from a surgery department from July 1st,2018 to July 14th,2018(before the application of quality control circle)and 436 medical records discharged from Nvember 1st,2018 to Nvember 14th,2018(after the application of quality control circle)were examined and analyzed throughout the acticity.The ICD coidings of primary diagnosis of those medical records were checked and analyzed.In view of the high coding error rate of the primary diagnosis,the reasons are analyzed from several dimensions,and the countermeasures are made and implemented according to the reasons found.Results A series of countermeasures were implemented throughout the activities of quality control circle.All of the writing of the clinician,the coding of the coders and the quality control of the electronic medical record system were improved after the of the quality control circle activities.And the accuracy of ICD coding for main diagnosis increased from 86.97%to 94.30%;quality control capability of team members was improved as well.Conclusion It turns out that the quality control circle could significantly improve the accuracy of ICD coding for main diagnosis on the home page of medical records.It means that the quality control circle plays an important role in improving the accuracy of the ICD coding for main diagnosis on the home page of medical records and should be implemented continuously in the later period.

关 键 词：品管圈 ICD编码 医院质量管理 住院病案首页 

分 类 号：R197.323[医药卫生—卫生事业管理]