FOCUS-PDCA循环在提升住院病案首页质量中的应用研究  

Application of the FOCUS-PDCA method in improving the quality of the front page of medical records

作　　者：韩天碧 田娇妮 柴小央 王晶晶[2] Han Tianbi;Tian Jiaoni;Chai Xiaoyang;Wang Jingjing(Department of Medical Records and Statistics Office,Shanxi Eye Hospital,Taiyuan 030002,China;Department of Medical,Shanxi Eye Hospital,Taiyuan 030002,China)

机构地区：[1]山西省眼科医院病案统计室,太原030002 [2]山西省眼科医院医务科,太原030002

出　　处：《实用医技杂志》2024年第11期828-831,共4页Journal of Practical Medical Techniques

基　　金：山西省眼科医院科研基金(Q202206)。

摘　　要：目的探讨FOCUS-PDCA循环在提升某院住院病案首页质量中的作用,为进一步提升住院病案首页数据质量提供参考依据。方法采用分层随机抽样法,按比例随机抽取本院2022年上半年、2023年上半年期间出院病案首页,分析FOCUS-PDCA循环实施前997份病案首页与实施后839份病案首页的填报完整率、疾病诊断选择及编码正确率、手术及操作选择及编码正确率等指标。结果FOCUS-PDCA循环实施前,病案首页总体缺陷率46.64%(465/997),FOCUS-PDCA循环实施后,病案首页缺陷率下降至30.01%(252/839),差异有统计学意义(χ^(2)=52.773,P<0.05)。与FOCUS-PDCA循环实施前相比,实施后病案首页缺陷数量及诊疗信息缺陷发生率均下降,病案首页主要手术及操作选择正确率、编码正确率均提高,差异有统计学意义(P<0.05)。尚未发现病案首页完整率、主要诊断选择正确率、主要诊断编码正确率的提升差异有统计学意义。具体分析缺陷项目后结果显示,各分项缺陷频次均低于未循环实施前。结论FOCUS-PDCA循环可有效提升住院病案首页数据质量。Objective To explore the effect of FOCUS-PDCA method in improving the quality of the front page of medical records in a hospital,and to provide reference for further management of the front page of medical records.Methods A stratified random sampling method was employed to select the front pages of medical records from the first half of 2022 and 2023.The completion rate,the accuracy rate of disease diagnosis,disease coding,surgical operation,and operation coding were compared between 2022(before improvement)and 2023(after improvement).Results After implementing the FOCUS-PDCA method,the defect rate decreased significantly from 46.64%to 30.01%,with a statistically significant difference(χ^(2)=52.773,P<0.05).Compared with before the implementation of the FOCUS-PDCA method,the number of defects and the incidence of defects in medical information of the front page of medical records decreased after the implementation.The accuracy of main surgical operation,and main operation coding of the front page of medical records in 2023 group were obviously higher than those in 2022 group(P<0.05).No statistical differences were found in the improvement of the completion rate,the accuracy rate of main disease diagnosis and main disease coding.After analyzing the specific defect items,the results indicated that the frequency of each sub item defect was lower than that observed prior to the implementation of the method.Conclusion FOCUS-PDCA method can effectively improve the quality of the front page of medical records.

关 键 词：病历记录 住院病案首页 FOCUS-PDCA循环 质量 

分 类 号：R197.323[医药卫生—卫生事业管理]