Objective To explore the effect of FOCUS-PDCA method in improving the quality of the front page of medical records in a hospital,and to provide reference for further management of the front page of medical records.Methods A stratified random sampling method was employed to select the front pages of medical records from the first half of 2022 and 2023.The completion rate,the accuracy rate of disease diagnosis,disease coding,surgical operation,and operation coding were compared between 2022(before improvement)and 2023(after improvement).Results After implementing the FOCUS-PDCA method,the defect rate decreased significantly from 46.64％to 30.01％,with a statistically significant difference(x2=52.773,P＜0.05).Compared with before the implementation of the FOCUS-PDCA method,the number of defects and the incidence of defects in medical information of the front page of medical records decreased after the implementation.The accuracy of main surgical operation,and main operation coding of the front page of medical records in 2023 group were obviously higher than those in 2022 group(P＜0.05).No statistical differences were found in the improvement of the completion rate,the accuracy rate of main disease diagnosis and main disease coding.After analyzing the specific defect items,the results indicated that the frequency of each sub item defect was lower than that observed prior to the implementation of the method.Conclusion FOCUS-PDCA method can effectively improve the quality of the front page of medical records.
关键词
病历记录/住院病案首页/FOCUS-PDCA循环/质量
Key words
Medical record/The home page of medical records/FOCUS-PDCA method/Quality
维普
万方数据