某醫學中心住院中病歷品質改善實務

Quality Improvement Practice of Active Medical Records at Certain Medical Center

黃怡菁(Yi-Ching Huang) ； 賴淑芬(Shu-Fen Lai) ； 高源忠(Yuan-Chung Kao) ； 孫茂勝(Maw-Soan Soon)

《病歷資訊管理》 9卷1期 (2009/09) Pp. 1-17

https://doi.org/10.29741/JMHIM.200909.0001

摘要

本院過去致力於出院病歷品質的提昇，且在認爲住院中即時審查，對病歷書寫品質的改善較有成效，但礙於病歷審查人力及主治醫師完成病歷之即時性問題等因素，對於住院中病歷品質並未做特別監控；而在準備國際評鑑(Joint Commission International Accreditation; JCIA)的過程中更警覺住院中病歷記錄的即時性、完整性，對團隊醫療照護模式的重要性，遂成立專案推動位院中病歷審查機制。
設立住院中病歷審查表爲工具，經初步審金結果發現：整體項目未達成百分比爲1.5%；各評項未達成百分比＞5%者共15項。歸納其原因並由本專案介入後，整體項目未達成百分比由1.5%降低至0.8%；各評項未達成百分比＞5%者由15項降低至1項。
爲驗證住院中即時審查，是否對病歷書寫品質的改善較其成效，本專案試著將執行成果和過去實施15年已有成效的出院後病歷審查結果，進行簡易的改善成果比較，雖然取樣對象及時間對照上未盡符合統計理論，但經校正後結果顯示，位院中病歷審查進步分數(3.02)大於出院後病歷審查進步分數(0.816)，應仍足以證實住院中即時審查對於病歷品質改善的成效，比出院後審查效采較佳。
住院中病歷品質審查已成爲本院常規病歷審金活動。

關鍵字

病歷品質 ； 病歷審查 ； 國際醫院評鑑

並列摘要

This particular medical center hospital (MCH) has been devoting itself to enhancing the quality of its patient medical records post hospital stay in the past. Although it's also recognized that to add an instant review (by a third party) of the medical record during the patient's hospital stay should significantly improve its quality, MCH failed to do so due to a few factors, such as the lack of trained quality-assurance staff members, difficulty in persuading attending doctors to promptly complete the medical records on-site, etc. However, during the preparation period prior to an inspection by the Joint Commission International Accreditation (JCIA), MCH realized the importance of the promptness in timing and completeness of active medical records to the medical care pattern of the team. Consequently, a promotion project of actively reviewing medical records during the patients' hospital stay was launched.
After setting up a tool called active medical record review form, the preliminary results showed that 1.5% failed to meet the overall standard, and 15 evaluating elements failed by a gap ＞5%. After inducing the probable causes, and implementing the new review system, the fraction failing the overall standard has dropped from 1.5% down to 0.8%, while only 1 evaluating element missed the standard by over 5% by now.
To validate whether or not instant review of medical records during the patient's hospitalization does improve the quality of medical records, this study made a simplified comparison between the results of the very project, where review was done during the patient's stay, and those of MCH's original review over the past 15 years, when the review was performed after the patient was discharged. Although the sampling method may not fully comply with statistical theory, the adjusted outcome showed that the improvement score of reviews done during the patient's stay (3.02) is significantly higher than the old one done after the patient was discharged (0.816). Such comparison outcome should serve as sufficient evidence that instant review of medical records during the patient's hospital stay is way more effective in improving medical record quality than reviews done post-hospitalization.
Now, active medical records quality review has become a daily routine at MCH.

並列關鍵字

medical record quality ； medical record review ； international hospital accreditation