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目的加强ICD编码质量管理,提高ICD编码正确率。方法分别对某院2015年和2016年出院病案首页的疾病分类编码和手术操作编码进行核对、检查、分类、汇总,使用描述性统计分析。采用PDCA循环质量控制理论,针对编码正确率低的现象,进行原因分析,科室成立质控小组,采取对相关人员进行针对性培训,编码人员持证上岗,完善HIS系统并安排专人维护编码库,修订病案首页质量相关管理办法等一系列措施。结果通过PDCA循环,实施改进措施后近一年的编码正确率数据显示,ICD编码质量逐步提高,编码正确率从2015年的50%到2016年1月份的65%,逐步提高到2016年12月份的94%,说明管理机制有效。个别改进效果不明显的项目将纳入下一轮的PDCA质量控制。结论应用PDCA循环的操作原理,可明显提高病案首页ICD编码正确率,能大幅提升编码的质量,促进病案管理水平的提高。
Objective To improve ICD coding quality management and improve ICD coding accuracy. Methods The disease classification codes and surgical operation codes of the first page of discharged medical records in a hospital in 2015 and 2016 were checked, checked, classified, summarized and used descriptive statistical analysis. The PDCA cycle quality control theory was adopted to analyze the reasons for the low coding accuracy. The QC team was set up in the department to conduct targeted training on relevant personnel, to certify the certified staff, to perfect the HIS system and to arrange special staff to maintain the coding base, Amendment of the first page of medical record quality management measures and a series of measures. Results According to the PDCA cycle, the coding accuracy of nearly a year after the implementation of the improvement measures showed that the quality of ICD coding gradually improved from 50% in 2015 to 65% in January 2016 and gradually increased to December 2016 94%, indicating that the management mechanism is effective. Individual improvement is not obvious effect of the project will be included in the next round of PDCA quality control. Conclusion The application of PDCA cycle principle can significantly improve the ICD coding accuracy of medical records, which can greatly improve the quality of coding and promote the improvement of medical records management.