Application of PDCA in Improving the Accuracy of Coding the Main Diagnoses on the Front Page of Inpatient Medical Records
Objectives This study aims to explore the types and causes of major diagnostic selection and coding errors on the front page of inpatient medical records and use the PDCA cycle method to improve the accuracy of main diagnosis selection and coding.Methods 300 medical records discharged from the hospital between June 1,2021 and June 30,2021 were randomly selected as the control group.After the PDCA cycle,300 medical records of discharged patients from January 1,2022 to January 31,2022 were randomly checked again to form the observation group.The accuracy rate of main diagnosis selection and the accuracy rate of main diagnosis coding before and after PDCA management were compared.Results The accuracy rate of selecting the main clinical diagnosis before PDCA was 72.6％,and the accuracy rate of coding the main diagnosis was 68.7％.The main types of main diagnosis coding errors were overgeneralization of main diagnosis,wrong selection of main diagnosis in tumor medical records,and coding errors of multiple site injuries.Clinicians'lack of clarity on the main diagnosis selection principles and coders'insufficient understanding of the main diagnosis selection principles were the main reasons for errors in main diagnosis selection and coding.After the PDCA cycle,the accuracy of selecting the main clinical diagnosis and the accuracy of coding the main diagnosis increased to 85.3％and 82.7％respectively.After the chi-square test,the difference was statistically significant.Conclusions Using the PDCA cycle method to conduct systematic training on the main diagnosis selection principles for clinicians and coders and requiring coders to read medical records,search and verify codes,communicate with clinicians,and improve quality control measures can improve the accuracy of selecting the main diagnosis and coding the main diagnosis.
NETL
NSTL
万方数据
维普
