PDCA在降低有创呼吸机编码漏报率的应用  

Application of PDCA in Reducing the False Negative Rate of Invasive Ventilator Coding

作　　者：吴小娟[1] 曲巍[1] 王祥堂 Wu Xiaojuan;Qu Wei;Wang Xiangtang(Binzhou Medical University Hospital,Binzhou 256603,China;不详)

机构地区：[1]滨州医学院附属医院,山东省滨州市256603

出　　处：《中国病案》2023年第5期8-10,共3页Chinese Medical Record

基　　金：滨州医学院附属医院现代医院管理专项研究项目(GLZD-05);滨州医学院人文社会科学项目(BY2019SK02)。

摘　　要：目的利用PDCA降低有创呼吸机编码漏报率,提高病案首页编码水平。方法收集2020年1月1日-2021年12月31日住院病案首页中涉及有创呼吸机操作的病案3427例,分析临床医师对呼吸机使用时间和操作名称的填写情况,用PDCA法对缺陷病案进行改进,对改善前后漏报率采用χ^(2)检验分析,对填报质量进行效果评价。结果有创呼吸支持技术编码漏报率改善前为60.13%,改善后降低为14.77%,差异有统计学意义(χ^(2)=655.91,P<0.001),其中心脏大血管外科、神经外科、重症医学科、急诊科、儿科的编码漏报率均有下降。结论运用PDCA法对病案首页有创呼吸机填写情况的质控和改进,可以大大降低编码漏报率,提高病案首页有创呼吸机编码的准确性和完整性,措施有效。Objectives This study aims to use PDCA to reduce the underreporting rate of invasive ventilator coding and improve the coding level of medical records.Methods This study collected 3,427 medical records involving invasive ventilator operations on the front page of inpatient medical records from January 1,2020 to December 31,2021 and analyzed clinicians'fill-in of ventilator use time and operation names.PDCA method was used to improve deficient medical records.The Chi-square test was used to analyze the false negative rate before and after improvement.The quality of submissions was evaluated.Results The coding miss rate of invasive respiratory support technology was 60.13%before improvement and decreased to 14.77%after improvement.The difference was statistically significant(χ^(2)=655.91,P<0.001).Among them,the under-reporting rates of cardiovascular surgery,neurosurgery,intensive care medicine,emergency department,and pediatrics all decreased.Conclusions Using the PDCA method to control and improve the quality of invasive ventilator filling on the front page of medical records can greatly reduce the rate of missed coding and improve the accuracy and completeness of invasive ventilator coding on the first page of medical records.The measures are effective.

关 键 词：PDCA 病案首页 有创呼吸机 编码 

分 类 号：R197.323[医药卫生—卫生事业管理]