Research and Analysis of the Effectiveness of Continuous Improvement of Ambiguous Medical Records in a Certain Hospital Based on the PDCA Cycle Method
Objectives To use the PDCA cycle management method analyze the causes of ambiguous medical records,and develop and implement improvement measures to improve the data quality of front page of medical records.Methods 83 ambiguous discharge medical records from a tertiary hospital in Beijing from January 1st,2022 to June 30th,2022 were selected as the control group before the circular management method,and 66 ambiguous discharge medical records from January 1st,2023 to June 30th,2023 were selected as the experimental group after the circular management method.Quality monitoring was conducted on all outgoing medical records.Based on the quality control results of the control group,to analyze the reasons for ambiguity in the medical records using the root cause method and draw a graph.Using the method of composition ratio to compare the factors causing ambiguous medical records before and after improvement,the composition ratio of influencing factors was tested using χ2.Results After implementing improvement measures using the PDCA cycle management method,the proportion of ambiguous medical records in the entire hospital decreased from 0.31%to 0.21%.The chi square test showed χ2=2631.23,P＜0.05.There was a total of 83 ambiguous medical records in the control group,including 38,16,and 12 cases caused by DRG grouping rule errors,clinical physicians filling in main diagnosis errors,and newborns missing birth weight or age,accounting for 45.78%,19.28%,and 14.46%,respectively.The cumulative proportion of the three reasons was 79.52%.After improving the PDCA cycle management method,a total of 66 medical records were not enrolled,of which 25 were ambiguous due to incorrect DRG grouping rules,accounting for 37.88%.Conclusions The overall inclusion rate of inpatient medical records in a certain hospital was relatively high,but there were still ambiguous medical records.Continuous improvement of ambiguous medical records in a certain hospital based on the PDCA cycle method was an effective management method.By continuously applying the PDCA cycle method,continuously improving and optimizing the medical service process and management system,we aimed to promote the continuous improvement of the overall quality of the hospital.
PDCA cycleAmbiguous medical recordsContinuous improvementImpact assessment
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