Application of PDCA in the Quality Management of Major Diagnoses
Objectives This study aims to explore the application of PDCA cycle method in improving the correct rate of clinicians'main diagnosis selection,so as to effectively improve the quality of the hospital's overall inpatient medical record front page data.Methods A total of 441 medical records from a hospital from January 1,2021 to March 31,2021 were randomly selected as the pre-intervention group.After PDCA improvement,562 medical records from October 1 to December 31,2021 were selected as the post-intervention group.The choice of main diagnosis was compared before and after the intervention.Results The main types of errors in the selection of the main diagnosis in tumor medical records were incorrect selection of the main diagnosis(30.65％),failure to combine the main diagnosis name with pathology(20.97％),and using postoperative or medical history as the main diagnosis(19.35％).The main reasons for the wrong selection of the main diagnosis were that some clinical physicians fill in the form based on experience or did not know how to fill in the form,and did not implement rectification according to the main diagnosis problems reported by the medical record management department.After the improvement,the correct rate of main diagnosis selection increased from 85.94％before the improvement to 95.55％(x2=28.811,P＜0.05),and the difference was statistically significant.Conclusions As a management tool,PDCA can effectively improve the accuracy of clinical physicians'main diagnostic selection,thereby improving the overall data quality of the inpatient medical record front page,and lay a solid foundation for providing objective and accurate diagnosis and treatment data for hospital management and specialist evaluation.It should be continuously promoted and used.
Main diagnostic optionsPDCA cycle methodContinuous improvement
万方数据
维普
