以品管圈手法提升門診病歷、出院病歷摘要之電子簽章完成率

因應政府大力推動紙本病歷無紙化的政策下，且符合實施電子病歷及互通補助計畫之電子病歷簽章率須達70％的基準，方可執行電子病歷報備事宜。藉由醫療資訊化的階段（包含電子病歷簽章完成），以便提高醫師就診與病人接受醫療照護的效率，並能減少醫療資源的浪費，提供民眾享有優質醫療照護的服務。故本專題運用品管圈的手法，針對逾時24小時門診病歷與出院病歷摘要之電子病歷完成簽章數，進行原因分析並提出具體改善措施，研擬改善方法為制定病歷管理規範與落實病歷紀錄與簽章完成的查核機制、提升醫事人員對於醫療資訊系統操作之熟練度與即時簽章的正確觀念、整合醫療資訊系統功能並優化操作介面，以茲建立院內良好簽章文化，提升病歷完成時效與即時簽章數。改善後成效為門診病歷24小時簽章完成率91.7％，進步率為16.7％，目標達成率114.9％；出院病歷摘要24小時簽章完成率92.8％，進步率9.7％，目標達成率151.9％。本專題藉由品管圈的手法提升門診病歷與出院病摘之簽章率的解決方案與成效供醫院做為參考之用。

關鍵字

電子病歷；電子簽章；門診病歷；出院病歷摘要

並列摘要

In response to the government's policy of vigorously promoting paperless medical records, and in line with the implementation of the electronic medical record and mutual subsidy program, the electronic medical record signing rate must reach at least 70% before the electronic medical record filing can be implemented. Throughout the stage of medical informationizing process (including the completion of electronic medical record signing), the ultimate goal is to improve the efficiency of doctors' visits and patients' medical care, and to reduce the waste of medical resources, hence, to provide the public with high-quality medical care services. Therefore, this topic uses the technique of the quality control circle to analyze the number of completed signatures of the electronic medical records for the 24-hour outpatient medical records and discharge medical records abstracts, analyze the reasons for un-signed records and propose specific improvement measures, and develop the procedure to setup medical record management standards. It is also concerned with verification mechanism for recording and signing completion, improvement of the proficiency of medical staff in the operation of the medical information system, and the correct concept of real-time signing, integrating the functions of the medical information system and optimizing the operation interface. Furthermore, it intends to establish a good signature culture in the hospital, improve the timeliness of completion of medical records and the number of instant signatures. The improved results were 91.7% of the 24-hour signing completion rate of medical records; the progress rate was 16.7% with a target achievement rate of 114.9%. The completion rate of 24-hour signing of the discharge summary was 92.8%, the progress rate was 9.7% with a target achievement rate of 151.9%. This topic also uses the methods of the quality control circle to improve the solution and effectiveness of the signing rate of outpatient medical records and discharged patients as a reference for the hospital.

並列關鍵字

electronic medical record ； electronic signature ； medical records ； discharge summary

國際替代計量

以品管圈手法提升門診病歷、出院病歷摘要之電子簽章完成率

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