從住院醫師觀點探討病歷品質提昇

Residents' Education on Medical Record Writing: A Questionnaire-based Study

林惠娥(Hui-O Lin) ； 李建德(Chien-Te Lee,) ； 曾昱龍(Yu-Lung Tseng) ； 劉家壽(Jia-Shou Liu) ； 李建國(Chien-Kuo Lee)

《Journal of Medical Education》 13卷1期 (2009/03) Pp. 24-34

https://doi.org/10.6145/jme.200903_13(1).0004

摘要

Aim: A questionnaire study was conducted among hospital residents upon completion of a medical record education symposium. In the questionnaire analysis, we aimed to investigate the impacts of the education program on the residents' training, medical record quality and learning satisfaction, respectively. In addition we wanted to analyze the association between these four aspects. Materials and Methods: A questionnaire study was conducted after a medical record writing program at the Chang-Gung Memorial Hospital, Kaohsiung in 2008. A total of 90 residents attended the training program and 69 questionnaires were eligible for analysis. The questionnaires contained four major categories: impact of education program on the hospital, individual's training program, medical record quality, and learning satisfaction. Comparisons between the medical and surgical residents as well as the junior and senior residents were performed. Correlation analyses were performed to test the association and a structural equation model analysis was used to determine whether there was any causal relationship. Results: There were no significant differences in the results between the medical and surgical residents in the four aspects and questionnaire analysis revealed similar scoring among the junior and senior residents. Correlation analyses found that there were positive correlations among the four major categories. The results of the structural equation model analyses revealed significant effects between the influence on resident training and medical record quality as well as learning satisfaction (p＜0.05). A significant difference was also noted between the influence on the hospital and resident training but there were no significant differences between influence on the hospital and learning satisfaction. Conclusion: Medical writing education program is of great value for resident training. It is very important to understand the residents' need for training programs to improve the medical record quality. In response to this need, approaches such as advanced education courses, consistency between medical orders and progress notes, revisions of writing formulations, and medical English courses should be implemented.

關鍵字

病歷品質 ； 病歷紀錄 ； 住院醫師

並列摘要

Aim: A questionnaire study was conducted among hospital residents upon completion of a medical record education symposium. In the questionnaire analysis, we aimed to investigate the impacts of the education program on the residents' training, medical record quality and learning satisfaction, respectively. In addition we wanted to analyze the association between these four aspects. Materials and Methods: A questionnaire study was conducted after a medical record writing program at the Chang-Gung Memorial Hospital, Kaohsiung in 2008. A total of 90 residents attended the training program and 69 questionnaires were eligible for analysis. The questionnaires contained four major categories: impact of education program on the hospital, individual's training program, medical record quality, and learning satisfaction. Comparisons between the medical and surgical residents as well as the junior and senior residents were performed. Correlation analyses were performed to test the association and a structural equation model analysis was used to determine whether there was any causal relationship. Results: There were no significant differences in the results between the medical and surgical residents in the four aspects and questionnaire analysis revealed similar scoring among the junior and senior residents. Correlation analyses found that there were positive correlations among the four major categories. The results of the structural equation model analyses revealed significant effects between the influence on resident training and medical record quality as well as learning satisfaction (p＜0.05). A significant difference was also noted between the influence on the hospital and resident training but there were no significant differences between influence on the hospital and learning satisfaction. Conclusion: Medical writing education program is of great value for resident training. It is very important to understand the residents' need for training programs to improve the medical record quality. In response to this need, approaches such as advanced education courses, consistency between medical orders and progress notes, revisions of writing formulations, and medical English courses should be implemented.

並列關鍵字

medical record quality ； resident education

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