門診急調病歷之原因分析與改善—以某區域教學醫院為例

Cause Analysis and Improvement of the Urgent Request of Outpatient Medical Records-Using a Regional Teaching Hospital as an Example

許禎莉(Francesca Hsu) ； 葉衣娜(I-Na Yeh) ； 黃秋宗(Paul Huang) ； 洪宇平(Yu-Ping Hong) ； 鍾佳容(Jia-Rong Jung)

《病歷資訊管理》 11卷2期 (2013/02) Pp. 15-21

摘要

在政府大力的輔導、推動下，各家醫院均投入相當的資訊人才以及資訊系統的開發與更新，以迎接電子病歷時代來臨，本專題主要探討當門診電子病歷上線後，實體病歷保存單位的病歷室，將開始配合醫院政策不調病歷，而為了協助門診時醫師看診習慣的改變以及能快速正確查詢電腦系統中保存的資料，資訊人員特別於醫令系統中增加緊急調閱病歷的功能，當診間因看診實際需要時，可依病人病歷號啟動「門診急調病歷」功能，此時病歷室人員即時抽調病歷後，以最快的速度將紙本病歷送達診間，這對病歷室是一個新的挑戰：調閱量的多寡關係著病歷室如何安排急調作業流程、如何機動性調度有限人力抽調及遞送病歷而不至於延遲看診時間、急調病歷的確實性…等均成為病歷室所需面對的課題，而在這些門診急調情況發生中：哪些是實際上需要調閱、哪些是可以不用調閱的，成為本專案研究重點。本專案運用品管圈手法，於門診電子病歷上線一個月後開始進行統計，以2010年3月至2010年10月，針對門診急調病歷原因分析，透過品管圈的改善手法，有效降低異常調閱情形，使病歷輸送人員更有效率的將病歷送達診間，減少病人等候時間，提升使用電子病歷的看診品質。

關鍵字

電子病歷 ； 門診急調病歷 ； 品管圈

並列摘要

Upon the many guiding and encouraging actions from the government, the majority of hospitals invested substantial IT and human capitals in constructing and renewing information system preparing for the coming age of electronic medical records.After the initiation of electronic medical record system, hospitals, in principle, tend not to use paper-based medical record during the medical services. However, in order to be helpful during the change of doctor's behaviors and assuring responsive and accurate retrieving data during outpatient services, our hospital provided urgent request of paper-based medical record as the complementary service upon doctor's request. Such service has become a new challenge to the staff at the medical record department. The requested volume is the key in maintaining adequate delivery time under limited working manpower. Therefore, reasoning the causes of urgent request was the aim of this study.This study employed the so-called quality control circle methods. We conducted data collection starting from March 2010, just one month after the initiation of electronic medical record system, to October 2010. After that we've analyzed the collected data and developed strategies for improvements using the quality control circle methods. The improvements in reducing the abnormal urgent request were effective in terms of faster delivery of paper-based medical record to destinations, reducing patient waiting time, and improving the overall outpatient medical service quality under the electronic medical record system.

並列關鍵字

Electronic Medical Record ； Quality Control Circle ； Urgent Request of Outpatient Medical Record