台灣POMR病歷記錄系統認知及實施概況初探分析

A Preliminary Probe into and Analysis of the Systematic Recognition and General Practice Situation of Problem-Oriented Medical Record in Taiwan

范碧玉(Bih-Yuh Fan) ； 周文鈺(Wen-Yu Chou) ； 張晏晏(Yen-Yen Chang)

《病歷資訊管理》 9卷2期 (2010/06) Pp. 51-71

https://doi.org/10.29741/JMHIM.201006.0004

摘要

病歷是病人就醫診療的重要記錄文件，透過病歷醫師在很短的時間內就能知悉病人的重要訊息，使其診療工作得以繼續進行。病歷除了是醫護人員在對病患進行診療活動時的溝通工具外，亦爲醫療院所申請保險給付重要憑據，也是病息及醫護人員在法律辯護時的重要依據，同時亦是教學研究的重要寶庫及醫院醫療品質監測的重要指標，故病歷記錄內容及方式極爲重要。而以問題爲導向的病歷記錄(Problem-Oriented Medical Record; POMR)已成爲國際問主要的病歷記錄方式，有鑑於此，爲捉弄病歷紀錄品質，新制醫院評鑑亦將病歷記錄內容及POMR的病歷記錄方式列爲病歷評鑑重點之一。
本研究藉由台灣病歷資訊管理學會受衛生署委託，2008年於全省辦理4場次之「以問題爲導向的病歷書寫品質提升研習會」，以問卷調查方式，瞭解國內醫療院所其病歷以POMR方式書寫的現況，以及醫護人員對POMR的認知及實施概況，以作爲將來衛生主管機關政策推動及加強訓練的參考。
由457份研習會的醫護學員所回應之有效問卷發現，於接受研習會前有94.1%聽過POMR病歷記錄方式，然而，完全瞭解POMR病歷記錄方式者僅有14.4%，而醫療院所實施POMR病歷記錄系統之比率爲62.6%。經研習後有73.5%表示其服務的醫療院所若實施POMR病歷記錄系統，一定會配合用比方式書寫病歷，不論醫師EE道理人員皆有將近九成的比例認爲POMR病歷紀錄方法較有邏輯架構，且有將近八成比例認爲較傳統病歷紀錄方式爲優，並認爲POMR病歷記錄方式的實施，領導者的支持及大力推動，是極爲重要的成功因素。

關鍵字

病歷書寫 ； 病歷書寫品質 ； POMR ； 以問題爲導向病歷記錄

並列摘要

Medical record is an important document made during the episode of a patient's seeking for medical help at hospital/clinic including hospitalization. With the aid of medical records a physician can easily grasp needed essential data of the patient in a jiffy in order to treat the patient swiftly and properly. Not only is medical record an indispensable communication tool among doctors, nurses, etc., it also serves as important proof to back up claims for healthcare reimbursement, important litigation evidence to protect the patient and the healthcare providers alike before a law court, treasured references for medical research and teaching, and one of important indicators to assure medical healthcare quality. Therefore, the content of medical records and the way of their documentation are both of extremely importance. Now, since Problem-Oriented Medical Record (POMR) has already become the principal way internationally, our country's new version of hospital accreditation has included the correctness of medical records and intention to adopt POMR as two must-be-done criteria.
Back in 2008 four sessions of a seminar aiming at improving medical record writing quality through POMR were held by Taiwan Health Information and Medical Record Management Association and the latter was entrusted by Department of Health. The intention of this study is to understand the current situation of POMR being used in domestic hospitals as well as general awareness of it by rank-and-file healthcare personnel through sending a specially designed questionnaire to all attendees of those seminar sessions. The findings of this study will be a reference for policy promotion and training enhancement of health authorities in the future.
Out of the 457 responded questionnaires, 94.1% claimed that they have heard about POMR seminar before attending it but only 14.4% said that they did completely understand the details of POMR and 62.6% of all hospitals/clinics they belonged to were using some POMR system. Also 73.5% of the responding attendees expressed that, because of the seminar, if their hospitals accepted POMR as one way of documenting medical records, they would definitely be cooperative and write medical records accordingly. Furthermore, close to ninety percent of both physicians and nurses considered POMR having a more logic framework, while over eighty percent of them thought it was simply better than the conventional way. We also realized in this study that the support and promotion from the leaders of the hospital is a crucial factor of success for POMR.

並列關鍵字

Medical Record Writing ； Medical Record Writing Quality ； POMR ； Problem-Oriented Medical Records