- 期刊
檢核表是改善家庭暴力被害人醫療紀錄的有效工具
A Checklist is an Effective Tool for Improving the Quality of Domestic Violence Victims' Medical Documentation
摘要
目的：本研究擬藉由高雄市衛生局8制定家庭暴力驗傷注意事項之檢核表為介入工具，於檢核表施行前後之年度家庭暴力防治指定醫院實地訪查時，針對家庭暴力被害人之醫療紀錄內容進行評值，以比較經檢核表之施行對於家庭暴力驗傷之醫療紀錄完整性改變情況。 村料與方法：本研究以高雄市衛生局於民國93年12月有關家庭暴力驗傷注意事項之檢核表的函文為介入性工具，收集民國93年7月及94年12月兩次家庭暴力驗傷指定醫院年度考察時，依隨機方式抽閱家庭暴力受害人之驗傷醫療病歷並加以評值，比較前、後測資料在其醫療紀錄完整性上的差異。 結果：本研究所抽閱評值之家庭暴力受害人驗傷醫療病歷，民國93年之評值病歷為前測資料計有131份，而民國94年者為後測資料者有145份。比較前、後測之資料，二者之年齡、性別、就醫之醫院等級及屬性均無差異。病歷紀錄在暴力事件之相關項目，包括施暴者、發生時間、發生地點、使用暴力方式等，後測之病歷具完整性者無論為醫師或護理之紀錄均顯著高於前測之病歷。而暴力傷害之臨床評估部份，後測之病歷僅醫師紀錄部份在外傷大小和外傷顏色狀況具完整性者顯著高於前測，護理紀錄部份則均無顯著差異。 結論：醫療人員使用家庭暴力驗傷注意事項作為家庭暴力臨床工作之檢核表，可以有效提升家庭暴力驗傷之醫療紀錄的完整性。
並列摘要
Medical documentation of domestic violence's victims is an important information for interdisciplinary cares. Unsatisfactory medical records were noted in the past annual reviews. In this study, a checklist was proposed as an intervention tool to the quality improvement of medical documents. Charts reviews were randomly performed on an evaluation structure in the annul hospital supervision pre and post the checklist application. There were 131 copies reviewed in the pre-phase and 145 in the post-phase. The time, victims stayed in the hospitals, was of no difference, which implied using a checklist did not take more time in clinical practice. And the document completeness of violent events, was all improved with statistic significance as the perpetrator, the time, the place, and the way that hurt in the doctors' and nurses' records. Also noted was the completeness of the evaluation of the wounds complained in doctors' records, such as wounds' size and wounds' color and state. However, no significant improvement was noted of the completeness of the evaluation of the wounds in nurses' records. This may be due to power imbalance of the nurse practitioners' state, which is asked only to follow the doctor's order and neglect nursing professional opinions. Therefore, nursing practitioners' clinical judgment is not well documented. To sum up, a checklist is quite effective to improve the quality of domestic violence victims' medical documentation.