PDSA循环管理在住院病案首页主要诊断填写的应用效果  

Effect of PDSA Cycle Management on Improving the Accuracy of Filling in the Main Diagnosis on the Front Page of Inpatient Medical Records

作　　者：张丽萍 刘海华 陈维平 Zhang Liping;Liu Haihua;Chen Weiping(Department of Internal Medicine,Longyan Hospital of traditional Chinese medicine,Longyan 364000,Fujian,China;不详)

机构地区：[1]龙岩市中医院,福建省龙岩市364000

出　　处：《中国病案》2025年第3期5-7,共3页Chinese Medical Record

摘　　要：目的分析实施PDSA循环管理前后住院病案首页主要诊断填写的正确率,探索PDSA循环管理在提高住院病案首页主要诊断填写质量的应用效果,持续不断地提高住院病案首页主要诊断填写正确率。方法随机抽取某院2022年1月1日—6月30日实施PDSA循环管理前699份住院病案首页作为对照组,2023年1月1日—6月30日实施PDSA循环管理后730份住院病案首页作为观察组。医院成立了住院病案首页主要诊断填写质量持续质改进小组,对2组住院病案首页主要诊断填写情况进行质控评价,采用χ^(2)检验比较实施PDSA循环管理前后住院病案首页主要诊断填写正确率情况。结果对照组699份住院病案首页主要诊断填写正确份数为545份,不正确份数是151分,正确率为77.97%;观察组730份住院病案首页主要诊断填写正确份数为679份,不正确的份数降低至51份,正确率提升至93.01%;实施前后主要诊断正确率对比结果分析差异有统计学意义。结论PDSA循环管理可以持续提高住院病案首页主要诊断填写正确率,能取得较理想的效果。Objectives The purpose of this study is to analyze the accuracy of recording the main diagnoses on the front page of medical records before and after the implementation of PDSA cycle management,explore the effect of PDSA cycle management in improving this accuracy,and continuously enhance the accuracy of recording the main diagnoses.Methods 699 medical records before PDSA cycle management were randomly selected as control group,and 730 medical records after PDSA cycle management were randomly selected as observation group.In addition,a continuous quality improvement team was set up to conduct quality control evaluation of the main diagnosis filling on the front page of medical records of the two groups.χ^(2) test was used to compare the accuracy of main diagnosis filling on the front page of medical records before and after the implementation of PDSA cycle management.Results Before the implementation of PDSA cycle management,545 of the 699 inpatient medical records in the control group had the main diagnosis filled in correctly,151 were incorrect,and the correct rate was 77.97%.After implementing the PDSA cycle management,the number of correct main diagnoses in the front page of the 730 inpatient medical records in the observation group was 679,the number of incorrect ones was reduced to 51,and the accuracy rate was increased to 93.01%.The difference in the correct rate of main diagnosis before and after implementation was statistically significant.Conclusions PDSA cycle management can continuously improve the accuracy of filling in the main diagnosis on the front page of the inpatient medical record and achieve relatively ideal results.

关 键 词：主要诊断 正确率 PDSA循环管理 住院病案首页 编码 病案质量 

分 类 号：R197.323[医药卫生—卫生事业管理]