- 期刊
JCI評鑑與病歷紀錄品質
Joint Commission International Accreditation and Quality of Medical Records
摘要
新制醫院評鑑及教學醫院評鑑，對於病歷書寫的想法有了新的改變，尤其是病程記載部分，於新制醫院評鑑5.1.4「病歷記載內容適當性」，「重點：診療紀錄記載，應依照問題導向病歷紀錄(POMR)方式記述，臨床路徑除外。」。近年來國內有多家醫院開始參加JCI (Joint Commission International)醫院評鑑，利用國際醫院評鑑檢視自己醫院的醫療服務品質，也利用JCI評鑑讓國際看到我國的醫療水平，本院於2006年（第一次參加）、2009年（再次參加）參加JCI評鑑，JCI評鑑對於病歷記載的格式、內容與團隊醫療照護的呈現更具體，藉由病歷記載的軌跡，了解醫院是提供一個以病人爲中心的照護團隊。每一個組織都力求籍由獲得、管理及訊息的使用，以提高病患的治療結果，以及個人和整體組織表現成效。(JCI, 2008, 3(上標 rd)) JCI評鑑中病歷仍然爲整個評鑑的核心，因爲它是提供醫療服務者高度依賴的一個訊息傳達與溝通的工具。完整的病歷可以將整個醫療服務呈現(Scalise, 2000)。而透過病歴溝通的範圍色括醫師、護理、藥劑、營養、復健病人與家屬等跨團隊的評估、治療與合作紀錄，而關於此部分的病歷紀錄要求，本院在2006年JCI評鑑後被列爲建議改善事項共有3項分別爲「MCI 13全院統一縮寫。MCI 19.4定期評估病歷內容品質和完整性。MCI 19.1提供足夠的病歷資訊，促進病人健康與治療照護的持續性。」，對於再次JCI參加評鑑的醫院而言，美國JCI總部要求對於建議改善事項必須提出策略性改善計劃，而此部份也對應於JCI評鑑中的QPS (Quality Improvement and Patient Safety)章節中的系統性品質改進計QPS 3.9臨床監測包括由領導者選定的病歷可得性內容和使用相關內容(Clinical monitoring includes those-aspects of availability, content, and use of patient records selected by the leaders.)。因此對於此部份的改善我們擬定了改善計畫，採用了電子與紙本同時改善的方式，藉由不斷與臨床間溝通和討論；建立新流程與改變獎懲辦法等激勵措施，同時採取循序漸進的方式陸續增加質審的項目與內容，籍以達到提昇病歷內容完整性之目標。
並列摘要
The new systems of hospital accreditation and teaching hospital evaluation have some novel changes in the idealism of writing up medical records, especially in the part of recording the illness progress. In the new hospital accreditation 5.1.4 or ”appropriation of the contents of medical records,” it's stated that ”the key point: medical records should always be in accordance with the manner of problem-oriented medical records (POMR), except clinical pathways.” In recent years, many hospitals in Taiwan started to take part in JCI (Joint Commission International) accreditation, for the purposes of not only examining their medical procedures by international hospital accreditation standards and evaluate the quality of their medical services, but also to let the outside world look in and realize our lofty medical establishments. This hospital participated in JCI accreditation for the very first time in July 2006 and once again in July 2009. In the process, JCL accreditation put great emphasis on the format and content of medical records, as well as on the more concrete presentation of team care, or through the trajectory formed by medical records to comprehend that an ideal hospital is no more than a patient-centered healthcare team. Each organization of the hospital strives to improve the outcome of patient treatments, individual and entire organization performance through information securing, managing, and utilization. (JCI 2008 3(superscript rd)) The medical record remains to be the core of assessment in JCI accreditation due to the fact that it's a tool of information transference and communication highly relied upon by providers of medical services. A complete and well-written medical record is able to depict the entire course of an appropriate medical care. (Scalise, 2000) The far-reaching range of communication through the medical record includes physicians, nurses, pharmacists, dieticians, rehabilitation teams, patients and their families, etc., and the natures of these interdisciplinary discussions include assessments, treatments, and cooperation records. Three improvement recommendations concerning medical records were raised in the 2006 JCI accreditation, and they are ”MCI 13 hospital-wide unification of abbreviations,” ”MCI 19.4 regular assessment of content quality and integrity of medical records,” and ”MCI 19.1 to provide adequate medical information to promote the patient's health and continuity in medical treatment/care.” As to the second time involvement with JCI accreditation, in which the headquarters of JCI in the States requested us that in respect of improvement planning we had to formulate a strategic proposal and to be presented in the QPS (Quality Improvement and Patient Safety) section. The result was QPS 3.9 clinical monitoring includes those-aspects of availability, content, and use of patient records selected by the leaders. Therefore, we made a strategy of improvement planning accordingly, which did elevate the quality of both electronic and paper medical records simultaneously by constant clinical communications and discussions; we set up new procedures and changes in the department of incentives and punishments; and we increased the quality and content of medical records step by step, all in the name of reaching the goal of enhancing the integrity content of medical records.