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題名 | 住院中病歷同期同儕審查之探討--以某醫學中心為例 |
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作者姓名(中文) | 陳琇玲; 黎憶萍; 楊伸崇; 吳巧雲; | 書刊名 | 中華公共衛生雜誌 |
卷期 | 14:1 1995.02[民84.02] |
頁次 | 頁103-110 |
分類號 | 419.26 |
關鍵詞 | 病歷; 同儕審查; 同期審查; 醫學中心; Medical record; Peer review; Concurrent review; Medical center; |
語文 | 中文(Chinese) |
中文摘要 | 病歷常作為衡量一家醫院醫療水準的基本工具,其要求的是提供即時、完整、正 確、一致的醫療行為紀錄。現今臺灣醫療機構病歷審查仍多半從事事後審查,尚未有同期審 查之研究報告出現。再加上病歷品質有量的審查及質的審查二方面重點,量的審查透過病歷 管理人員進行足足有餘。但限於醫療的專業性,質的審查則最好透過同儕進行審查,方能公 正的判定。本研究即對病歷同期審查方法進行探討,針對數種基本病歷設計〞住院中病歷審 查表〞,並在臺北市某醫學中心進行二次住院中病歷抽樣同儕審查。研究結果顯示,入院記 錄( Admission Note )方面, 其品質以主訴( Chief Complaint )、 現在病況( Present Illness )、 一般外表評估( General Appearrance )、 身體檢查( Physical Examination )、及初步診斷( Impression )較佳,家族史( Family History )、過往 病史( Past History )、生命徵象( Vital Sign )、特殊發現( Specific Finding ) 較差。但入院記錄( Admission Note )於 24 小時內完成之時效控制良好。在住院摘要( Admission Summary )審查結果,缺乏率高,其填寫品質除了家族史( Family History ) 及處理計劃( Case Plan )外,其餘良好, 且 24 小時完成率高。 病程記錄( Progress Notes )方面,2 天以上未寫比率仍高,但病程記錄記載簡略之病歷比率卻低。手術記錄( Operating Room Record )填寫品質良好,但應加強改進檢體( Specimen )及估計失血量 ( Estimated blood loss )欄位空白情況。文末並針對本研究之缺失及可能改進方向進行 探討。 |
英文摘要 | Medical records review is a basic tool for evaluating the quality of a hospital. Major criteria includes timeliness, completeness, accuracy, and consistency of completing the medical records. Currently in Taiwan, most medical records review is retrospective-oriented, and there are scarecely any research reports concerning concurrent review. Furthermore, in reviewing the quantity of medical records, it is usually done via MRA (Medical Record Administor) or MRT (Medical Record Technician) . However, because medical service is highly technical, it is better to monitor quality through peer review rather than by MRA. The purpose of this study is to design a "Medical Record Concurrent Review Form" and then test it in a medical center. Inpatient charts were sampled during two specific periods. Physicians, including the superintendent and several senior physicians, were recruited as the peer reviewers. Eventually, the statistic data were presented for four basic categories of medical records: Admission Note, Admission Summary, Progress Note, and Operating Room Record. At the end of the article, limits of this study are stated and possible topics for future research are suggested. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。