- 期刊
建立病歷摘要中文化範本─以五種診斷為例
Establishing Model Chinese Medical Record Abstracts: Using Five Kinds of Diagnoses as Examples
摘要
近年來病歷中文化之議題一直被熱烈討論，衛生署於2010年成立「病歷中文化推動小組」陸續推動13項病歷表單中文化、進行病歷中文化問卷調查、專家訪談、醫院試辦、醫學專有名詞翻譯，目前醫學院之病歷寫作教育仍以英文為主，若未從醫學教育即開始進行中文病歷寫作教育，則醫師仍會以英文病歷為主要書寫方式。為了符合醫療法規定及衛生署政策，醫療院所開始提供病人申請中文病歷摘要之服務，且需於7日內提供病人，此政策直接影響醫師書寫中文病歷摘要之困難度，因此對於中文病歷摘要之製作如何與英文病歷摘要一致且快速完成，即為醫院面臨重要課題。醫院自2009年起推動病歷化相關作業，陸續完成檢驗、檢查報告中英文並列呈現、中文病歷摘要格式制定、中文病歷摘要釋出作業流程訂定等，本計劃擬建立標準疾病病歷摘要中文範本，選定5類疾病製作中文病歷摘要範本，經專家訪查找出適合轉譯之項目，透過翻譯工具及專家指導完成5類疾病之字彙翻譯。透過字彙翻譯所製的中文病歷摘要範本，再請院內醫護同仁進行審閱，調查醫護同仁對於此範本之滿意度及中英文病歷摘要一致性分析，調查結果發現醫護同仁對於採用範本所製之中文病歷摘要之品質滿意度達100%，而中英文病歷摘要經比對後一致率達97.5%。經過此次計劃執行，可確認依疾病別建立中文病歷摘要範本提供醫師使用為可行之方式，故未來將持續針對其他常見疾病類型透過轉譯制訂中文病歷摘要範本，提供院內醫護同仁更便利、省時之書寫範本以縮短製作時間進而降低病人等候時間。
並列摘要
Over recent years, the change of writing medical records in Chinese has been fervently discussed in the circle. In 2010, the Health Department of Taiwan (DOH) established a special taskforce in order to promote ”Medical Records in Chinese.” The group has since conducted quite a few questionnaire surveys and hospital trials, interviewed experts, engaged in medical jargon translation, and promoted 13 Chinese standard forms to be adopted by medical recording professionals. However, in the circle of Taiwan's medicine education, the majority of schools still teach students to write medical charts in English as usual. Should there be no training in writing medical record in Chinese at the school level; future doctors would most likely keep on using English as the chief language in their health record writings.To meet medical regulations and the DOH's policies, medical facilities have already started to provide a system for patients to apply for Chinese medical records. Once applied, such record has to be issued within seven days, which directly influenced doctors' habit of writing medical records apparently with increased difficulties. The issue of how to compile English and Chinese medical records with reasonable speed has become an important challenge for all hospitals alike.Since 2009, Hualien Tzu Chi hospital has carried out a series of steps that are related to Chinese medical record. The formats of bilingual medical charts, test results, and records are duly established, and a release process of Chinese medical record is instituted. The plan has selected five diseases as a starter in setting standardized Chinese medical records. During the standardizing process, experts are consulted to ensure accurate translation. The disease-related jargons are translated and completed through translation tools and experts instructions.The standardized Chinese medical record samples are reviewed and surveyed by a hospital staff member at Hualien Tzu Chi Hospital, and the member further analyzes the records for satisfaction and consistency. The survey resulted in 100% satisfaction with the Chinese medical records and 97.5% with their consistency.Through the execution of the plan, standardized Chinese medical record samples are deemed feasible for the doctors. In the future, the standardizing process could also be established for other common diseases, and the records could save hospital staff's time and the patients' waiting.