PDCA 循环改进对病案首页中主要诊断正确选择的影响分析

摘要

Purpose The paper aims to improve the selection accuracy of principal diagnosis in the first page of medical record by means of PDCA cycle. Method Statistics is carried out on the selection accuracy of principal diagnoses in the first pages of medical records archived from January to June of 2014; the reasons for low accuracy are analyzed and PDCA-cycle improvement is implemented on that ground. Then, statistics is made on the selection accuracy of principal diagnoses between July and December of 2014 after improvement. Result After the implementation of PDCA, the selection accuracy of principal diagnosis in the first page of medical record is significantly increased from previous 93.04% to 98.26%, and the difference between the two has statistical significance (P<0.01). Conclusion The accuracy of principal diagnosis in the first page of medical record can be improved by implementing PDCA-cycle quality management.%目的：利用PDCA循环改进法提高病案首页主要诊断选择的正确率。方法统计某医院2014年1月～6月归档病案首页中的主要诊断选择正确率，分析正确率低的原因，据此实施PDCA循环改进，之后统计2014年7月～12月实施改进后主要诊断选择的正确率。结果PDCA循环改进方案实施后，病案首页主要诊断选择正确率明显提高，实施前主要诊断选择的正确率为93.04%，实施后为98.26%，二者比较，差异有统计学意义（P＜0.01）。结论实施PDCA循环改进方案能提高病案首页主要诊断的正确率。