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題名 | 我國醫院病歷書寫相關問題探討=The Medical Record Writing Problem in Taiwan |
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作者 | 范碧玉; 許清曉; 賴朝英; 楊皓婷; | 書刊名 | 病歷管理期刊 |
卷期 | 5:1 民94.10 |
頁次 | 頁1-10 |
分類號 | 419.26 |
關鍵詞 | 病歷書寫指引; 病歷品質; 病歷管理; Guidelines of medical record writing; Quality of medical record; Medical record management; |
語文 | 中文(Chinese) |
中文摘要 | 病歷是病人就醫診療的重要記錄文件,透過病歷醫師能在很短的時間內就能知悉病人的重要訊息,使其診療工作得以繼續進行。病歷除了是醫護人員在對病患進行診療活動時的一種溝通工具外,亦為醫療機構申請保險給付重要憑據以及病患及醫護人員在法律辯護時的重要依據,同時也是教學研究的重要寶庫及醫院醫療品質監測的重要指標。 國內各醫院病歷記錄品質普遍不佳,為了提昇全國醫院病歷書寫品質,衛生署於2003年特委託中華民國醫療品質協會、台灣病歷管理學會共同規劃病歷書寫研討會,聘請國內對病歷書寫有專精且熱心的學者編製教材,並於北區、南區各辦一場研討會,教導各醫療院所醫師及病歷記錄相關人員有關病歷書寫的技巧。本研究乃對研討會參與者作問卷調查,以了解各醫院病歷書寫的相關問題及病歷書寫品質不佳的相關因素。 兩場研討會共有510人參加,問卷回收率為72.9%,參加者醫師助理(含專科護理師)占31.9%,病歷管理人員占22.6%,醫師占21.5%。於調查參加研討會者其醫院病歷是由誰書寫的問卷填答中,得知醫學中心81.8%的病歷是由醫師親自書寫,區域醫院由醫師親自書寫的只占37.0%,地區醫院由醫師親自記錄的占42.0%,區域與地區此二層級醫院的病歷由醫師助理及專科護理師代寫的比例相當高,約占將近一半。探討國內病歷書寫品質不佳的原因,有 21.8%的參加者認為沒受過病歷書寫課程專門訓練是最主要的因素,其次為病人太多沒時間書寫占20.2%,英文非母語書寫困難占17.2%。 至於如何改善與提昇病歷書寫品質,有26.9%的參加者表示提供病歷書寫指引為最有效的方式,有10.2%的人認為應把病歷書寫品質列為醫院評鑑的項目之一,9.1%參加者表示應把病歷書寫品質作為健保核減重要項目之一。此外,加強主治醫師對住院醫師病歷書寫的指導責任也是一項被認有效的改善方法。如何提昇醫師英文病書歷寫能力則為國內醫師與醫院需長期努力的課題。 |
英文摘要 | Medical record of patient is an important legal document with which the medical and other personnel communicate to one another and to continue with the care of the patient where-ever he goes. It also serves as a record with which to request payment from insurance agencies, and to protect medical personnel from possible malpractice lawsuits. Furthermore, the patient record is necessary in the evaluation of the quality of the medical care and for clinical investigation of diseases in the future. The content of the patient record is generally not good at all levels of hospitals in Taiwan. To correct the deficiencies, the Department of Health of Taiwan requested The Association for Healthcare Quality, R.O.C. and Taiwan Medical Record Management Society to arrange symposia in the north and the south of the island to educate doctors and other related hospital workers as to how to write medical records appropriately. To learn the possible causes that contribute to the poor quality of the medical record keeping, we distributed questionnaires to the participants after each symposium. There were a total of 510 participations in the two symposia, of which 72.9% responded to the questionnaires. The participants consisted mostly of physician's assistants or nurse specialists, medical record managers, and doctors. To the question of who is writing the medical record, the proportion of the doctor who writes patient record is 81.8% in Medical Centers (those hospitals with bed number over 500 and have been judged to have appropriate patient care and teaching capabilities by the Taiwan Joint Commission of Hospital Accreditation, TJCHA); 37% in Regional Hospitals (bed number between 250 and 500 with or without teaching capabilities); and 42% in the Local Hospitals (bed number below 250). To the inquiry of the causes of the poor quality of medical record keeping, 21.8% answered that they had not received any course in this type of work; 20.2% gave the lack of time to write, and 17.2% complained of unfamiliarity in English as the reasons. As to the point at issue of how to improve the quality of medical record, the following were the answers: (1) provision of guidelines to write patient record properly (26.9%); (2) inclusion of the merit of medical record keeping as one of the major criteria to be inspected during the hospital accreditation visit by the TJCHA (10.2%); and (3) addition of the clarity of the record as an important item in judging for the payment by the Bureau of the National Health Insurance (9.1%). In addition, escalation of the responsibility of the attending physicians to strengthen the ability of the resident physicians' patient records is considered to be another effective method. Persistent effort will be needed to improve the quality of patient's record keeping in Taiwan. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。