摘要
目的 在DIP支付背景下,PDCA循环管理模式对康复医院住院病案首页主要诊断填写及编码正确率的影响情况,为医院质量管理提供参考。方法 运用PDCA循环法,通过建立健全专业团队及质量控制体系、完善考核制度、加强培训、建立跨部门沟通机制等实施方法,比较实施前2023年1月1日—12月31日和实施后2024年1月1日—12月31日各1600份病案首页的主要诊断填写正确率和编码正确率,运用χ^(2)检验分析其变化,评估实施效果。结果 实施PDCA循环前对照组主要诊断填写正确1118例,实施后观察组主要诊断填写正确1468例,主要诊断填写正确率由69.88%上升至91.75%,χ^(2)=246.882,P<0.05,正确率差异具有统计学意义;实施PDCA循环前对照组主要诊断编码正确1331例,实施后观察组主要诊断编码正确1544例,主要诊断编码正确率由83.19%上升至96.50%,χ^(2)=155.377,P<0.05,正确率差异具有统计学意义。实施PDCA循环前后,主要诊断错误类型包括以下5种:ICD编码错误、以后遗症作为主要诊断、xx术后作为主要诊断、功能诊断缺失、临终状态作为主要诊断。结论 DIP支付背景下通过运用PDCA循环可显著提高康复医院住院病案首页主要诊断填写正确率、主要诊断编码正确率,有助于提高医疗服务的准确性和实现医保基金的合理分配。
Objectives This article analyzes how to improve the accuracy of filling in the main diagnosis and coding on the front page of the inpatient medical record of a rehabilitation hospital through the PDCA cycle management model under the background of DIP payment.Methods Using the PDCA cycle method,implementation measures such as establishing and improving professional teams and quality control systems,refining evaluation systems,strengthening training,and creating interdepartmental communication mechanisms were adopted.The accuracy rates of main diagnosis entries and coding on i,600 inpatient medical record front pages before(January 1,2023-December 31,2023)and after(January 1,2024-December 31,2024)implementation were compared.The changes were analyzed using the x test to evaluate the effectiveness of the intervention.Results Before the implementation of PDCA cycle,1,118 cases in the control group were correctly filled in the main diagnosis.After the implementation,1,468 cases in the observation group were correctly filled in the main diagnosis.The correct rate of flling in the main diagnosis increased from 69.88%to 91.75%(χ^(2)=246.882,P<0.05).The difference of accuracy rate was statistically significant.Before the implementation of PDCA cycle,1,331 cases in the control group had correct main diagnostic codes.After the implementation,1,544 cases in the observation group had correct main diagnostic codes,and the correct rate of main diagnostic codes increased from 83.19%to 96.50%(χ^(2)=155.377,P<0.05).The difference in accuracy was statistically significant.Before and after the implementation of PDCA cycle,the main types of diagnostic errors include the following five types:ICD coding error,sequelae as the main diagnosis,xx postoperative as the main diagnosis,functional diagnosis loss,and terminal state as the main diagnosis.Conclusions Under the background of DIP payment,the application of PDCA cycle can significantly improve the accuracy of main diagnosis filling and main diagnosis coding on the first page of inpatient medical records in rehabilitation hospital,which is helpful to improve the accuracy of medical services and realize the rational allocation of medical insurance funds.
作者
王杰
戴益辉
周维
陈骕
Wang Jie;Dai Yihui;Zhou Wei;Chen Su(Shanghai Second Rehabilitation Hospital,Shanghai 200441,China)
出处
《中国病案》
2025年第9期17-19,共3页
Chinese Medical Record
