【摘要】 目的 探讨在按病种分值付费下采用PDCA质量控制管理模式对医院病案质量的提升效果。方法 将PDCA质量控制管理前2020年1月1日-2020年12月31日41 934份和PDCA质量控制管理后2021年1月1日-2021年12月31日42 159份，共计84 093份出院病案作为研究对象，对比2组病案3日归档率、甲级病案率、住院病案首页主要诊断编码正确率的差异。结果 PDCA质量控制管理后病案3日归档率由73.37%提升至93.71%，经χ~2检验，χ~2=6911.425,P<0.001；甲级病案率由90.17%提升至97.08%，经统计分析χ~2=557.152,P<0.001；住院病案首页主要诊断编码正确率由80.23%提升至90.27%，经统计分析χ~2=169.703,P<0.05，差异均具有统计学意义。结论 按病种分值付费下基于PDCA循环的病案质量控制管理可明显提高病案3日归档率、住院病案首页主要诊断编码正确率、甲级病案率，为按病种分值付费支付提供了数据时效与质量的保障，可广泛用于各级医院病案管理工作中。更多还原

【Abstract】 Objectives This study aims to explore the effect of PDCA quality control management model on improving the quality of hospital medical records under the condition of paying according to the point value of disease.Methods 41 934 copies before PDCA quality control management from January 1, 2020 to December 31,2020 and 42 159 copies after PDCA quality control management from January 1, 2021 to December 31, 2021, a total of 84 093 copies, were discharged Medical records as research objects.The differences in the 3-day filing rate of medical records, the rate of Class A medical records, and the correct rate of main diagnostic codes on the front page of inpatient medical records were compared between the two groups. Results After PDCA quality control management, the 3-day filing rate of medical records increased from 73.37% to 93.71%(χ~2=6911.425,P<0.001).Class A case rate increased from 90.17% to 97.08%(χ~2=557.152,P<0.001). The correct rate of main diagnostic codes on the front page of inpatient medical records increased from 80.23% to 90.27%(χ~2=169.703,P<0.05).The differences were all statistically significant. Conclusions The quality control management of medical records based on the PDCA cycle under the payment of disease points can significantly improve the 3-day filing rate of medical records, the correct rate of main diagnosis codes on the front page of inpatient medical records, and the rate of Class A medical records. It provides data timeliness and quality assurance for payment by disease score, and can be widely used in the management of medical records in hospitals at all levels.更多还原