基于质量改进工具提高主要诊断编码正确率

来源期刊：广州医药 | 88-93 发布时间：2023-07-27 收稿时间：2025/11/13 18:33:49 阅读量：39

作者：: 于磊,

邓活清,

周爱莲,

龚启英,

熊小兰,

王湛泽,

谭华珍,

关键词：: 品管圈病案首页主要诊断编码正确率; quality control circle home page of hospitalization medical records main diagnosis coding accuracy

DOI：: 10.3969/j.issn.1000-8535.2023.06.016

收稿时间：: 2023-01-04
修订日期：
接收日期：
引用总数：: 12

目的利用品管圈工具提高某三甲医院住院病案首页主要诊断编码正确率。方法成立品管圈小组,选取2022年11月出院日期前200份住院病案首页作为开展品管圈前的对照组,按照出院科室分层抽取2021年8月1日—2022年3月31日的2 007份首页作为开展品管圈后的研究对象,对上述首页的主要诊断填写及疾病分类编码进行核对、检查、汇总统计。针对主要诊断编码错误率高的现象,从人、法、测3个维度进行分析,根据找出的原因制定对策并执行。根据具体情况使用χ²检验或者四格表资料的Fisher确切概率法检验比较品管圈前后主要诊断编码正确、错误份数的差异。结果开展一系列改进措施后医生主要诊断填写正确率从95.00%上升到98.01%,编码员主要诊断编码正确率从97.50%上升至99.55%,住院病案首页主要诊断编码正确率从93.50%提高到97.56%,临床医师的书写质量、编码员的编码质量均有改善。品管圈开展前后主要诊断编码正确、错误份数差异有统计学意义。通过开展品管圈,标准化了一个院级规范、多个院级编码共识、两个科级工作工具和机制以及一个科级绩效分配方案。结论品管圈质量改进工具能有效提高病案首页主要诊断编码正确率,后期应持续开展。

Objective To improve the accuracy of main diagnostic codes on the home page of inpatient medical records in a Class III Grade A Hospital by using the quality control circle．Methods The Medical Record Department set up a quality control circle group．A total of 200 inpatient medical records' home pages were selected as the control group before the quality control circle carried out,which patients were discharged in November 2022．Home pages of 2 007 inpatient medical records from August 1,2021 to March 31,2022 were selected according the discharge department as the research objects after the quality control circle carried out．The main diagnosis filling and disease classification codes on those home pages of the above medical records were checked and summarized．We analyzed the reason of the high error rate of the main diagnostic codes from three dimensions of people,law and test．Countermeasures were formulated and implemented according to the identified causes．Fisher exact probability method of four grid data or χ² test were used to compare the correct copies of main diagnostic codes before and after the quality control circle according to the specific situation．Results The writing quality of clinicians and the coding quality of coders were improved after a series of improvement measures were carried out．The correct rate of doctors' main diagnostic codes increased from 95.00% to 98.01%,the correct rate of coders' main diagnostic codes increased from 97.50% to 99.55%,and the correct rate of main diagnostic codes on the home page of inpatient medical records increased from 93.50% to 97.56%．The number of correct copies of main diagnostic codes before and after the development of the quality control circle was statistically significant．Through the development of the quality control circle,one institute level specification,multiple institute level coding consensus,two department level work tools and mechanisms,and one department level performance allocation scheme have been standardized．Conclusions The application of the quality control circle tool can effectively improve the accuracy of the main diagnostic codes on the home page of the inpatient medical record,which should be continued in the later period．

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