摘要
目的采用PDCA循环管理法,分析歧义病案的产生原因,制定和实施改进措施,从而提高住院病案首页数据质量。方法选择北京市某三级医院2022年1月1日-2022年6月30日出院的歧义病案83份作为循环管理法前的对照组,2023年1月1日-2023年6月30日出院的歧义病案66份作为循环管理法后的实验组,对2组共计149份歧义病案进行质量监控。根据对照组的质控结果,用根因法分析病案产生歧义的原因并绘制成图。采用构成比的方法比较改进前后组歧义病案产生因素,影响因素构成比采用χ^(2)检验。结果应用PDCA循环管理法实施改进措施后,全院歧义病案构成比从0.31%降低到了0.21%,经卡方检验,χ^(2)=2631.23,P<0.05,差异具有统计学意义。对照组83份歧义病案中,DRGs分组规则原因、临床医师主要诊断填写错误、新生儿漏填出生体重或年龄导致的歧义病案分别有38份占45.78%、16份占19.28%和12份占14.46%,3项原因累积占比为79.52%。应用PDCA循环管理法改进之后,未入组病案合计有66份,其中因DRGs分组规则导致的歧义病案有25份,占37.88%。结论基于PDCA循环法对某院歧义病案进行持续改进是一种有效的管理方法。
Objectives To use the PDCA cycle management method analyze the causes of ambiguous medical records,and develop and implement improvement measures to improve the data quality of front page of medical records.Methods 83 ambiguous discharge medical records from a tertiary hospital in Beijing from January 1st,2022to June 30th,2022 were selected as the control group before the circular management method,and 66 ambiguous discharge medical records from January 1st,2023 to June 30th,2023 were selected as the experimental group after the circular management method.Quality monitoring was conducted on all outgoing medical records.Based on the quality control results of the control group,to analyze the reasons for ambiguity in the medical records using the root cause method and draw a graph.Using the method of composition ratio to compare the factors causing ambiguous medical records before and after improvement,the composition ratio of influencing factors was tested usingχ^(2).Results After implementing improvement measures using the PDCA cycle management method,the proportion of ambiguous medical records in the entire hospital decreased from 0.31%to 0.21%.The chi square test showedχ^(2)=2631.23,P<0.05.There was a total of 83 ambiguous medical records in the control group,including 38,16,and 12 cases caused by DRG grouping rule errors,clinical physicians filling in main diagnosis errors,and newborns missing birth weight or age,accounting for 45.78%,19.28%,and 14.46%,respectively.The cumulative proportion of the three reasons was 79.52%.After improving the PDCA cycle management method,a total of 66medical records were not enrolled,of which 25 were ambiguous due to incorrect DRG grouping rules,accounting for 37.88%.Conclusions The overall inclusion rate of inpatient medical records in a certain hospital was relatively high,but there were still ambiguous medical records.Continuous improvement of ambiguous medical records in a certain hospital based on the PDCA cycle method was an effective management method.By continuously applying the PDCA cycle method,continuously improving and optimizing the medical service process and management system,we aimed to promote the continuous improvement of the overall quality of the hospital.
作者
石伟奇
李粱
王洋
张祺
Shi Weiqi;Li Liang;Wang Yang;Zhang Qi(Beijing Daxing District People's Hospital,Beijing 102600,China;不详)
出处
《中国病案》
2024年第12期4-6,共3页
Chinese Medical Record
关键词
PDCA循环
歧义病案
持续改进
效果评价
PDCA cycle
Ambiguous medical records
Continuous improvement
Impact assessment
