- 期刊
以品管圈手法提升出院病歷書寫完成時效
Efforts to Enhance Timely Completion of Discharge Medical Records by Quality Control Circle Approaches
摘要
病歷為病人醫療診療過程及結果重要的資訊紀錄，病歷記錄完整及完成時效對病人醫療照護、醫院評鑑、健康保險申報、醫療爭議及教學研究具有重要影響，本院致力於提升出院病歷完成時效，唯出院病歷完成時效受到主治醫師工作排程、作業流程管理、病歷書寫資訊化等因素影響而延宕，改善出院病歷完成時效為醫院重視的課題及評鑑重要點項之一，因此成立專案以品管圈手法提升出院病歷完成時效。本專案期間自2008年5月~2012年12月為期4年8個月之出院病歷共160,330本，本院導入品管圈手法以三個面向進行專案改善，（1）制度面：修訂病歷記錄管理規定、修訂出院病歷書寫獎懲、住院醫師逾期列入晉升評核及門診病歷減送作業。（2）系統面：推動住院醫囑系統上線等電子病歷上線、線上查詢未完成病歷系統管理、簡訊自動傳呼。（3）作業流程面：審查人員當日完成量審查、電話通知主治醫師即時完成出院病歷、即時審查醫師完成之病歷。本專案改善成效由2008年5月之3日內出院病歷平均完成率75.4%提升至2012年平均完成率91.9%，明顯進步；自2008年5~12月之7日內出院病歷平均完成率84.2%提升至2012年平均完成率98.6%，有顯著進步。利用品管圈手法研擬出院病歷書寫獎懲制度增加獎勵金、電話通知主治醫師及即時審查醫師完成病歷等對策，可以提升病歷完成時效、增進病歷管理單位、醫護團隊合作關係，並提升醫護團隊對組織向心力。
並列摘要
Medical records are documents containing important medical information about patients’ treatment history and outcomes. Complete and timely medical records are essential for quality patient care, hospital accreditation, hospital claims to the National Health Insurance, medical dispute cases, and teaching and research. We at Chi Mei Hospital are committed to improving timely completion of discharge medical records, as it is one of the critical items and requirements in hospital accreditation. We’ve identified some factors causing the delay, including doctors' promptness, sloppy procedure management, and the implementation of electronic medical records. Therefore, a management project was developed to enhance the efficiency in this regard. This project was carried out from May 2008 to December 2012, lasting for 4 years and 8 months, during which a total of 160,330 discharge medical records were reviewed. Using the QC Circle approach, we implemented improvement measures in three areas: 1. In administrative policies, revisions were made to the Medical Records Management Regulations, Awards and Penalties regarding discharge medical records, Resident Advancement Policy to stress the importance of timely completion of medical records, and the delivery procedures of outpatient medical records. 2. In systemic phases, Electronic Medical Record System, which facilitates inpatient medical notes, discharge medical summary, and lab results transmission, Online Checking System for incomplete medical records, and Automatic Messaging were either promoted or implemented. 3. In practical workflow, assigned monitors daily reviewed incomplete medical records, reminded doctors to complete discharge medical by phone, and timely evaluated the completion status of such records. As to the outcomes of this project, the completion rate of medical records within a 3-day period after discharge increased by 21.9%, i.e. from 75.4% in 2008 to 91.9% in 2012, while the 7-day completion rate increased by 17.1%, or from 84.2 % to 98.6%. The improvements are remarkable. This paper describes our past efforts of using QC circle strategies, including reformulating the reward & penalty system targeting on improving timely completion of discharge medical records, using telephone to remind attending physicians, timely monitoring the process, etc. We found out that not only they did what we wanted, but also improved the cooperative relationship between the Medical Records Management Office and medical teams, and beefed up the centripetal force of the medical teams toward our institution as well.