摘要
目的探讨基于PDCA[计划(plan)、实施(do)、检查(check)、行动(action)]循环法的住院病案管理对病案首页信息质量和主要诊断编码正确率的影响。方法选取我院2023年6月-2025年7月期间住院病案83856例作为研究对象,根据时间分为两组。2023年6月-2024年6月期间实施常规住院病案管理的42139例住院病案为对照组,2024年7月-2025年7月期间实施基于PDCA循环法的住院病案管理的41717例住院病案为观察组。比较两组住院病案首页信息质量(患者基本信息缺陷、住院过程信息类缺陷、诊疗信息类缺陷、费用信息类缺陷)及主要诊断编码情况(诊断选择错误、编码错误、编码遗漏)。结果与对照组相比,观察组住院病案首页信息总缺陷率较低,其中患者基本信息缺陷、住院过程信息类缺陷、诊疗信息类缺陷、费用信息类缺陷发生率均低于对照组(P<0.05)。与对照组相比,观察组主要诊断编码正确率较高,其中诊断选择错误、编码错误、编码遗漏发生率均低于对照组(P<0.05)。结论基于PDCA循环法的住院病案管理可提升住院病案首页信息质量及主要诊断编码正确率,减少病案信息缺陷、主要诊断及编码错误发生,值得推广应用。
Objective To explore the impact of inpatient medical record management based on PDCA(plan,do,check,action)cycle method on the quality of information on the front page of medical records and the accuracy of main diagnostic codes.Methods 83856 cases of hospitalized medical records in our hospital from June 2023 to July 2025 were selected as the research object and divided into two groups according to the time.42139 cases of inpatient medical records that implemented the routine inpatient medical record management from June 2023 to June 2024 were taken as the control group,and 41717 cases of inpatient medical records that implemented the inpatient medical record management based on PDCA cycle method from July 2024 to July 2025 were taken as the observation group.The information quality of the first page of inpatient medical records(patients’basic information defects,inpatient process information defects,diagnosis and treatment information defects,expense information defects)and the main diagnostic codes(diagnostic selection errors,coding errors,coding omissions)were compared between the two groups.Results Compared with the control group,the total defect rate of the front page information of the inpatient medical record in the observation group was lower,and the incidence rates of patients’basic information defect,hospitalization process information defect,diagnosis and treatment information defect,and expense information defect in the observation group were lower than those in the control group(P<0.05).Compared with the control group,the correct rate of main diagnostic codes in the observation group was higher,and the incidence of diagnostic selection errors,coding errors and coding omissions in the observation group were lower than those in the control group(P<0.05).Conclusion the management of inpatient medical records based on PDCA cycle method can improve the information quality of the front page of inpatient medical records and the correct rate of main diagnosis codes,and reduce the information defects of medical records and the occurrence of main diagnosis and coding errors,which is worthy of popularization and application.
作者
李浩瀚
张文晋
Li Haohan;Zhang Wenjin(Affiliated Hospital of Southwest Medical University,Luzhou,Sichuan 646000,China)
出处
《首都食品与医药》
2026年第5期101-104,共4页
Capital Food Medicine
关键词
住院病案首页
病案管理
诊断编码
质量控制
First page of inpatient medical record
Medical record management
Diagnostic code
Quality control
