國際醫院評鑑對病歷管理訂定政策與程序之影響

Effects on Policy and Procedure Formulation Regarding Medical Record Management by JCIA

范碧玉(Bih-Yuh Fan) ； 陳慧敏(Hui-Min Chen) ； 江翠如(Tsui-Ju Chiang) ； 李苓令(Ling-Ling Lee)

《病歷資訊管理》 11卷1期 (2012/06) Pp. 22-41

https://doi.org/10.29741/JMHIM.201206.0003

摘要

國際醫院評鑑標準第13章「溝通與資訊管理」的第18個標準，是管理各醫院所訂政策和程序的母法。全院所有的規章辦法在公布前需經審核、批准，並定期審查，且有日常管控機制，而員工都要熟讀並熟悉所有與他們工作相關的政策和程序。臺大醫院即依上訂定了院內「規章制定暨管理要點」供各單位遵循，以有效管理院方之各項規範制定。臺大醫院依據院內「規章制定暨管理要點」及國際醫院評鑑標準第13章要求之5個必要條文基準，制定了7個重要的病歷管理規章，並據以制定標準作業程序書及指導書。新修訂的病歷管理規章，除病歷管理同仁需遵循外，全院同仁亦需了解及配合，故病歷資訊管理室積極參與院內各項準備國際醫院評鑑之活動，也搭配年度病歷隱私保護週運動，將重點特別加強宣導，並設計單位自評表及不定期派員查核各單位，直到全院所有同仁都了解與遵守重要的病歷規範，即達到國際醫院評鑑所要求的精神與意涵。

關鍵字

國際醫院評鑑（JCIA） ； 溝通與資訊管理（MCI） ； 政策和程序（P&P） ； 知識管理系統（KM）

並列摘要

The 18th standard set forth in Chapter 13: Management of Communication and Information of Standards of Joint Commission International Accreditation (JCIA) is the basic norm of creating management policies and procedures of all hospitals. Each and every rule or procedure set by a hospital has to be thoroughly reviewed and approved before proclamation, then it should be followed by periodically reviews and modifications if found necessary, and routinely controlled by the management practices. Every employee must familiarize oneself with his/her work-related policies and procedures. Accordingly, National Taiwan University Hospital (NTUH) has established an internal bylaw called ”Key Points for Regulation Formulation and Management” for its own various departments to follow, to properly and effectively manage the hospital’s affairs of all kinds.In accordance with such ”Key Points” bylaw and the five essential documentation basics mentioned in the same Chapter 13 of the JCIA standards, NTUH has developed seven important medical record management regulations to moderate the making of relevant standard operation procedure (SOP) and instruction booklets.About the newly established medical record management regulation, aside from that the staff members of medical information management should observe it closely, the rest employees at the hospital also need to understand what's going on and cooperate. Thus not only would the medical record management staff actively participate in the various preparative activities at all different departments of the hospital for JCIA, but also initiate an annual campaign of medical privacy week, focusing on strengthened advocacy and lectures, and designing a unit-self-assessment form and checking the status of compliance until all staff members are well aware of and compliance with important record management regulations and standards. That is, to achieve what JCIA requires whether purposely just in spirit or meaningfulness.

並列關鍵字

Joint Commission International Accreditation (JCIA) ； Management of Communication and Information (MCI) ； Policy & Procedure (P&P) ； Knowledge Management (KM) System