病歷電子化單張對病歷厚度及儲存空間影響探討

A Study in the Impact of EHR on the Thickness of Health Records and Storage Space

薛德興(Te-Hsing Hsueh) ； 徐靜瑩(Ching-Ying Hsu) ； 徐均宏(Chun-Hung Hsu)

《病歷資訊管理》 10卷2期 (2011/12) Pp. 33-47

https://doi.org/10.29741/JMHIM.201112.0004

摘要

醫院導入醫療資訊系統運用後，醫事人員由電腦輸入病歷紀錄，以列印病歷紀錄單張取代傳統手寫病歷，使病歷愈來愈厚，造成病歷儲存區可容納病歷數量逐年遞減，本研究抽樣統計門診、急診及住院病歷所含病歷單張，量測出每次就醫後病歷厚度成長。研究結果，門診初診平均增加11張單張，每月增加病歷長度為1,648.5公分，門診複診每次平均增加2.5張表單，每月增加病歷長度為1,996.0公分。急診單次平均增加6.1張單張，每月初診增加長度為748.4公分；複診增加長度為314.4公分。住院病歷每天平均增加10張病歷單張，每月增加病歷長度為1,709.7公分；各類報告單及病歷表單回收歸檔每月增加779.1公分。本研究與台大醫院85年研究比較，門診病歷相差3倍；急診病歷僅小幅增加0.8張；住院病歷相差1倍，主要原因是門診紀錄及護理紀錄已導入電腦化列印單張，造成病歷厚度大幅增加。本研究結論：每年病歷成長為863.5公尺，換算成病歷櫃佔用空間需13.36坪。病歷儲存空間一直是病歷管理者主要課題，建議電子化列印單張改以雙面列印或接續列印方式，以減少增加紙張；儘快發展完善電子病歷系統後，開始病歷無紙化；以及加快病歷掃描速度，以減緩病歷儲存壓力。本次研究以表單增加的速度，推論病歷儲存空間的需求，作為未來空間規劃及病歷銷毀速度的參考，並作為實施電子病歷無紙化效益評估根據。

關鍵字

電子化病歷 ； 診間醫囑系統 ； 病歷檔案管理 ； 病歷厚度

並列摘要

After the introduction of the new electronic hospital information system, medical personnel key in and print out medical records through the use of computers to replace the traditional handwritten medical record sheets, thus resulting in thicker individual medical records and yearly decreases of storage capacity for medical records. In this study, the sampling method was adopted to tally the outpatient, emergency, and inpatient medical records in sheets and measure the increase in medical record thickness after each medical consultation.Our results show that on average, there is an increase of 11 health record sheets for one outpatient after his/her first visit, or an accumulation of the total thickness of 1,648.5 cm every month for this category alone. In the subsequent visits of an outpatient, there is an increase of 2.5 medical record sheets per session, or an accumulated medical record thickness of 1,996.0 cm. In the emergency department, there is an average increase of 6.1 sheets for the first visit by a patient, or an increase of 748.4 cm for the first emergency visits every month. For the subsequent visits, the thickness increase is 314.4 cm per month. For the hospitalized patients' medical records, there is an increase of 10 medical record sheets for each person, or an increase of 1,709.7 cm in thickness every month.In conclusion, as we compared the results to those of the research conducted by NTU Hospital in 1996, we found there was an increase of outpatient medical records tripled in sheet numbers and an increase of emergency medical records of 0.8 sheets, and the hospitalization medical record sheets doubled in sheet numbers. An increase of 863.5 meters in thickness per year and the cabinet space need to increase 13.36pins square meters. That is, the printing of the electronic health records, especially the outpatient record sheets and nursing sheets have been the main reasons for the greatly increased medical records thicknesses.The issue of medical record storage space has always been an issue of concern for the medical record keepers. It is recommended that the electronic printing to be changed from single- to double-sided printing or continuous printing and start paperless health records after developing a comprehensive electronic health record system at an earlier time in order to increase speed for scanning medical records and reduce storage pressure. In this study, the rate of increase of the tables and forms and inferences of the storage space demands have served as a reference for future space planning and the rate of medical record destruction and shall serve as a basis for assessing the effectiveness of paperless health record implementations.

並列關鍵字

Electronic Health Record ； Computer-based Physician Order Entry System ； Medical Record File Management ； Medical Record Thickness