疾病分類是病歷管理業務中極具專業的一部份,與醫療研究、衛生統計、醫療費用申報有著重要的關係。疾病分類編碼的正確與完整有賴於充足的專業人力和素質以及其他相關因素的配合才能達成。 本研究採問卷調查法,探討100床以上醫院病歷部門疾病分類人員的工作負荷、對工作的評價和人力推估。結果得知:在工作負荷方面,醫學中心每人每天平均編碼本數與編碼時間較其他醫院多,有96.2%醫院除了編碼外尚需從事癌症登記、病歷管理等工作。而醫師紀錄潦草與不完整等因素亦會影響編碼速度和完整。在工作評價方面,醫學中心、公立學校附設醫院、榮民醫院的疾病分類人員各別對『工作受到肯定』、『工作獲得成就感』和『有良好的教育訓練機會』的滿意度較高。而公衛、護理背景的疾病分類人員亦認為『工作可以發揮專長』。在人力估算方面,影響人員數最直接因子是出院病人次,模式如本文結果所述。建議相關單位多舉辦疾病分類研討會和衛生署建立疾病分類人員專業資格的認定。
Classification of disease is a very professional part of medical records management. It is related with medical research, health statistics and reimbursement system. The accuracy and completeness of disease coding depend on the quantity and quality of manpower and other relative factors. Samples were the disease coders of medical records department in hospital with over 100 beds by questionnaires. The purpose of this study was to explore the workload, job evaluation and manpower estimation. Results: on the aspect of workload, those of medical center, hospitals with beds over 100 and hospitals affiliated with public school are heavier than other hospitals. Besides disease coding, there are 96.2% hospitals coders still doing cancer registration, medical records management etc. The illegible and incomplete records from doctors also have influence on coding speed and completeness. One the aspect of job evaluation, the disease coders from medical center, hospitals affiliated with public school, veteran hospitals have higher satisfaction on work confirm, sense of achievement and training opportunity respectively, The disease coders from public health and nursing also have higher satisfaction on developing special skill. On the aspect of manpower estimation, the direct factor of influencing manpower is the number of discharge patients. We suggest relative institutes to conduct more training course of disease coding and government to establish qualification of disease coders.
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