在国际疾病分类10编码中采用网络和计划-做-检查-行动
1Department of Medical Record, Meishan People's Hospital, Meishan 620000, Sichuan Province, China. shanhmbnnp755706@163.com.
World journal of clinical cases
|July 12, 2024
概括
将计算机网络与计划-执行-检查-行为 (PDCA) 管理模式集成显著提高了国际疾病分类第十版 (ICD-10) 编码准确性和效率. 这种综合方法改善了医疗记录管理和对程序员和患者的满意度.
科学领域:
- 医疗信息学 医疗信息学
- 健康信息管理 管理健康信息
- 质量改进方法 质量改进方法
背景情况:
- 计算机网络在医疗保健中越来越重要,用于管理医疗记录.
- 计划-做-检查-行为 (PDCA) 模型和国际疾病分类第十版 (ICD-10) 编码系统在临床环境中表现有前途.
- 关于网络系统和PDCA在ICD-10编码中的协同应用的研究有限.
研究的目的:
- 研究将计算机网络系统与PDCA管理模型集成到ICD-10编码过程中的影响.
- 评估编码准确性,效率和整体医疗记录管理方面的改进.
主要方法:
- 一项回顾性研究分析了来自梅山人民医院的768份出院医疗记录.
- 记录被分为一个控制组 (n=232) 和一个实施PDCA管理的观察组 (n=536).
- 关键绩效指标包括编码准确度,时间,完成率和满意度在各组之间进行了比较.
主要成果:
- 使用PDCA的观察组在3-24个月的时间内,与对照组相比,显示出更高的编码精度和医疗记录完成率 (P <0.05).
- 观察组的编码时间显著减少.
- 编程人员满意度 (80.22%与53.45%) 和患者满意度 (84.89%与51.72%) 在PDCA实施组显著更高 (P <0.05).
结论:
- 计算机网络和PDCA管理模型的联合使用大大提高了ICD-10编码.
- 这种整合可以提高医疗记录编码的准确性,效率,完成率和满意度.
- 该研究强调了PDCA在网络医疗保健系统中的价值,以优化临床编码.
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