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題名 | 病歷寫作要點與常見錯誤=Medical Record Writing |
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作 者 | 許清曉; | 書刊名 | 病歷管理期刊 |
卷期 | 5:2 民95.04 |
頁次 | 頁30-43 |
分類號 | 419.26 |
關鍵詞 | 病歷書寫; 病歷內容管理; Medical record writing; Medical record contents management; |
語文 | 中文(Chinese) |
中文摘要 | 台灣各醫院的病歷書寫內容,因為數十年來主治醫師工作忙,大多數不自己書寫,而導致病程及醫師的思考邏輯多半沒能從病歷上很快地看出來,無法瞭解住院病患的病情,更看不出醫療的品質。其實越來越少的醫師不寫病歷的主要原因之一是因為對英文不熟。本篇文章列舉目前台灣病歷內容最緊急需要加強的項目;並建議用子句式英文,簡潔地記載,希望能夠藉此先充實內容。 病歷內容需要改進的部分很多,但作者建議先加強幾個項目,讓需要從病歷瞭解病況的人員,能夠不必東翻西翻地、很清楚地、很快地瞭解病況。最重要的幾項為: (1). TPR sheet:詳細填寫各種主要治療用藥、檢查處置及其結果、以及意外進展在體溫表上,就能使這部分成為瞭解病人住院經過最簡要清楚的記錄;(2). Progress note宜以problem-oriented medical record (POMR)方式記載,內容一定要寫出醫師對病況的分析(Assessment)。這部分最能顯示醫師的能力、看出醫療的品質,不過也是台灣病歷最需要糾正加強的部分;(3). Admission note中的history taking、physical examination等都要很詳細、準確。如此,在病患住院時,就能夠對病情及其相關因子有正確的掌握、選擇適當的檢驗項目、可以對症下藥、不會延誤適當的醫療,也可藉此作適當的病人衛教;(4). 因為病歷電子化,加上對每天的病情缺乏深入的思考、分析、整理,而有許多複製及張貼以前輸入的記錄情事,致使閱讀病歷者每天讀相同的記載,不知哪些事情是今天的新發展,這也是首先必須改正、使我們的病歷較符合國際水準的部分。 其他,數位相片的利用、各種摘要的正確寫法、出院摘要的寫法、昂貴抗生素使用的理由如何記載、儘量少用縮寫、病歷常見的錯誤英文等都是需要特別注意、趕快改善的問題。 |
英文摘要 | The quality of medical records in Taiwan has deteriorated alarmingly over the last 30-40 years. The reasons include attending physicians that are too busy to write patient records and that are not that familiar with the English language and therefore avoided writing. English is being promoted in Taiwan as the language to be used in medical records because it is the international language for science and medicine. As the first step in improving the content of the records, the author encourages the doctors to employ clauses or phrases, omitting subjects or verbs in most of the sentences in these records, and write without fear of making grammatical errors. There are four major deficits in our medical records writing that should be remedied immediately. (1) Main medications, key test results, and other important events during hospitalization should be charted in the TPR sheet. This will allow the hospital course of the illness to be illustrated clearly in the TPR sheet. (2) Problem-oriented medical records (POMR) are a better way than the S.O.A.P. to organize the daily clinical progress and the plan of management. The doctor must provide his/her assessment of the patient's response to the therapy. (3) More detailed history taking and physical examination should be performed. This should quickly point the doctor's diagnostic and therapeutic efforts in the right direction. (4) Computerized patient records will make things easier. However, copying and pasting of the same records made previously, as has been done widely, should be avoided. Other items, such as digitized photography for visible lesions, weekly summaries, the discharge note, stating the reasons for prescribing antibiotics in the progress notes, reduction of the use of abbreviations, and correction of certain errors in English, etc, all need to be improved or implemented as soon as possible. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。