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題名 | 建置術前評估及術後記錄提醒系統--提昇病歷記錄完整性及維護病人安全之專案研究=Development of a Remind System for Preoperative Assessment and Postoperative Recording--Enhancing Patient Safety and Medical Record Quality |
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作者 | 林惠娥; | 書刊名 | 病歷管理期刊 |
卷期 | 5:1 民94.10 |
頁次 | 頁21-36 |
分類號 | 419.26 |
關鍵詞 | 病人安全; 手術紀錄; 病歷紀錄品質; Patient safety; Operation record; Medical record quality; |
語文 | 中文(Chinese) |
中文摘要 | 在資訊不對稱的醫療環境下,病患往往是居於弱勢的一方。本研究的目的在針對外科醫師應於手術前後記載的各項術前評估及術後記錄建置提醒系統,減少發生醫療錯誤的可能性,增進病人手術安全,促進醫病關係和諧。以web-based為基礎的提醒系統由病人安全、醫囑執行及互動關懷等三個構面著手,以開刀問題為中心,在複雜且互動緊湊的住院醫囑中,分別以開刀排程及op-record輸入點為系統串聯術前、術後提醒之 key point,建置開刀前每日、開刀後三日內每日提醒機制,由系統將前後關聯的體溫、血壓…等數字資料格式化,成為比較具有價值的參考資訊。藉由提醒系統的建立,可提高術前評估紀錄率及術後記錄之完整率各20%,有效減少人為疏忽進而增進病人手術安全。 |
英文摘要 | The main purpose of the current project is to establish a remind system to be implemented in the electronic medical chart, aiming at improving the quality of the preoperative assessment and postoperative procedure recoding. The system is constructed via selected variables in the interlink database to enhance patient safety and reciprocal understanding. Accordingly, medical orders can be placed and enacted more completely. Piloted by surgical operation schedule, a remind mechanism for medical recoding will be effected daily before surgery and within 3days after the operation. The system is subjected to list vital signs and related bio-data to provide information for accomplishing a safe surgery. On the other hand, the related medical writing is estimated to enrich 20% in its content perse. Hopefully, the patient-centered safe surgery mechanism can thus be fulfilled at least in part via using the current remind system. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。