職能治療病歷功能之重要性與達成度調查

本研究目的為探討：(1) 各項病歷功能之重要性，(2) 各項病歷功能於現行病歷之達成度，及 (3) 病歷功能之重要性與達成度是否吻合。共有85 名職能治療師填寫「職能治療病歷紀錄功能之重要性與達成度」問卷。重要性方面 (1-5 分)，前三重要之病歷功能為 (1) 設定治療目標及計畫（平均：4.4）、(2) 掌握個案特性或病情（平均：4.3）以及 (3) 呈現個案療效及變化（平均：4.2）（評分為1-5 分）。達成度方面（1-10 分），前三達成度高之功能為 (1) 評鑑審查需求（平均: 7.3）、(2) 職能治療申報健保給付需求（平均：7.3）以及 (3) 設定治療目標及計畫（平均：7.0）。不同領域治療師間，有三項功能之重要性或達成度有顯著差異 (p ＜ 0.05)，包括臨床推理依據之重要性、個案資料儲存建檔方便檢閱之重要性、以及臨床推理依據之達成度。病歷紀錄功能之重要性與達成度為中度相關 (Spearman ρ =0.64)，二者不完全吻合。本研究可使治療師時有明確病歷改良方向，節省病歷改良之時間與精力。

關鍵字

病歷紀錄；職能治療；重要性；達成度

並列摘要

The purposes of the study were to investigate: (1) the importance of each goal of medical records, (2) the attainment of each goal on existing medical records, and (3) the consistency between the importance and the attainment of goals. We used a self-designed questionnaire to collect 85 occupational therapists’ perspectives. As for the importance of each goal (1-5 points), the three most important goals included (1) setting intervention goals and their corresponding intervention programs (mean: 4.4), (2) understanding characteristics of patients (mean: 4.3), and (3) presenting the patients’ changes and treatment effectiveness (mean: 4.2). Regards the attainment of each goal (1-10 points), the three most attained goals included (1) meeting the need of hospital evaluations (mean: 7.3), (2) meeting the need of national health insurance declaration (mean: 7.3) and (3) setting intervention goals and their corresponding intervention programs (mean: 7.0). The importance of each goal had a moderate correlation with the attainment of each goal (Spearman ρ = 0.64). Results of this study enable clinicians to identify which areas of medical records could be improved, thereby facilitating the process of revision of medical records.

並列關鍵字

Medical records ； Occupational therapy ； Importance ； Attainment

被引用紀錄

古芳瑜（2017）。改良「職能復健評估綜合評量表」應用於社區思覺失調症個案〔碩士論文，國立臺灣大學〕。華藝線上圖書館。https://doi.org/10.6342/NTU201702880

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職能治療病歷功能之重要性與達成度調查

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