PDCA在主要诊断质量管理中的应用  

Application of PDCA in the Quality Management of Major Diagnoses

作　　者：苏滔凤 黎欢 杜剑亮 Su Taofeng;Li Huan;Du Jianliang(Medical Records Department,The Seventh Affiliated Hospital of Sun Yat-sen University,Shenzhen 518107,Guangdong Province,China;不详)

机构地区：[1]中山大学附属第七医院病案管理科,广东省深圳市518107

出　　处：《中国病案》2024年第11期19-21,共3页Chinese Medical Record

摘　　要：目的探讨PDCA循环法在提高临床医师主要诊断选择正确率中的应用,有效提升医院整体住院病案首页数据质量。方法随机抽取某院2021年1月1日-2021年3月31日441份病案作为干预前组,经过PDCA改进后,抽取2021年10月1日至12月31日562份病案作为干预后组,对比分析干预前后临床医师主要诊断选择的情况。结果肿瘤病案主要诊断选择错误(30.65%)、主要诊断名称未结合病理(20.97%)、使用术后或者病史作为主要诊断(19.35%)是主要诊断选择错误的前3名。部分临床医师根据经验填写或者不知如何填写、未针对病案管理科反馈的主要诊断问题落实整改是主要诊断选择错误的主要原因;改进后主要诊断选择正确率从改进前的85.94%提升至95.55%,(χ^(2)=28.811,P<0.05),差异具有统计学意义。结论PDCA作为一种管理工具,能有效地提升临床医师主要诊断选择正确率,从而提高整体住院病案首页数据质量,为医院管理、专科评价提供客观、准确的诊疗数据打下牢固的基础,应持续推广使用。Objectives This study aims to explore the application of PDCA cycle method in improving the correct rate of clinicians'main diagnosis selection,so as to effectively improve the quality of the hospital's overall inpatient medical record front page data.Methods A total of 441 medical records from a hospital from January 1,2021 to March 31,2021 were randomly selected as the pre-intervention group.After PDCA improvement,562 medical records from October 1 to December 31,2021 were selected as the post-intervention group.The choice of main diagnosis was compared before and after the intervention.Results The main types of errors in the selection of the main diagnosis in tumor medical records were incorrect selection of the main diagnosis(30.65%),failure to combine the main diagnosis name with pathology(20.97%),and using postoperative or medical history as the main diagnosis(19.35%).The main reasons for the wrong selection of the main diagnosis were that some clinical physicians fill in the form based on experience or did not know how to fill in the form,and did not implement rectification according to the main diagnosis problems reported by the medical record management department.After the improvement,the correct rate of main diagnosis selection increased from 85.94%before the improvement to 95.55%(χ^(2)=28.811,P<0.05),and the difference was statistically significant.Conclusions As a management tool,PDCA can effectively improve the accuracy of clinical physicians'main diagnostic selection,thereby improving the overall data quality of the inpatient medical record front page,and lay a solid foundation for providing objective and accurate diagnosis and treatment data for hospital management and specialist evaluation.It should be continuously promoted and used.

关 键 词：主要诊断选择 PDCA循环法 持续改进 

分 类 号：R197.323[医药卫生—卫生事业管理]