- 期刊
住院中病歷同期同儕審查之探討－以某醫學中心為例
A Summary Report of Concurrent Peer Review of Inpatient Medical Records in a Medical Center
摘要
病歷常作為衡量一家醫院醫療水準的基本工具，其要求的是提供即時、完整、正確、一致的醫療行為紀錄。現今台灣醫療機構病歷審查仍多半從事事後審查，尚未有同期審查之研究報告出現。再加上病歷品質有量的審查及質的審查二方面重點，量的審查透過病歷管理人員進行足足有餘。但限於醫療的專業性，質的審查則最好透過同儕進行審查，方能公正的判定。本研究即對病歷同期審查方法進行探討，針對數種基本病歷設計“住院中病歷審查表”，並在台北市某醫學中心進行二次住院中病歷抽樣同儕審查。研究結果顯示，入院記錄(Admission Note)方面，其品質以主訴(Chief Complaint)、現在病況(Present Illness)一般外表評估(General Appearrance)、身體檢查(Physical Examination)、及初步診斷(Impression)較佳，家族史(Family History)、過往病史(Past History)、生命徵象(Vital Sign)、特殊發現(specific Finding)較差。但入院記錄(Admission Note)於24小時內完成之時效控制良好。在住院摘要(Admission Summary)審查結果，缺乏率高，其填寫品質除了家族史(Family History)及處理計劃(Case Plan)外，其餘良好，且24小時完成率高。病程記錄(Progress Notes)方面，2天以上未寫比率仍高，但病程記錄記載簡略之病歷比率卻低。手術記錄(Operating Room Record)填寫品質良好，但應加強改進檢體(Specimen)及估計失血量(Estimated blood loss)欄位空白情況。文末並針對本研究之缺失及可能改進方向進行探討。
並列摘要
Medical records review is a basic tool for evaluating the quality of a hospital. Major criteria includes timeliness, completeness, accuracy, and consistency of completing the medical records. Currently in Taiwan, most medical records review is retrospective-oriented, and there are scarecely any research reports concerning concurrent review. Furthermore, in reviewing the quantity of medical records, it is usually done via MRA (Medical Record Administor) or MRT (Medical Record Technician). However, because medical service is highly technical, it is better to monitor quality through peer review rather than by MRA. The purpose of this study is to design a ”Medical Record Concurrent Review Form” and then test it in a medical center. Inpatient charts were sampled during two specific periods. Physicians, including the superintendent and several senior physicians, were recruited as the peer reviewers. Eventually, the statistic data were presented for four basic categories of medical records: Admission Note, Admission Summary, Progress Note, and Operating Room Record. At the end of the article, limits of this study are stated and possible topics for future research are suggested.
延伸閱讀
- 郭明和（2007）。住院病人醫療服務供給之探討~以某醫學中心為例〔碩士論文，高雄醫學大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0011-1107200709550700
- 鄭嘉惠、郭書麟、王拔群（2013）。病人住院經驗調查結果初探－以某醫學中心為例。醫療品質雜誌，7(6)，99-102。https://www.airitilibrary.com/Article/Detail?DocID=a0000532-201311-201401270032-201401270032-99-102
- 周秋芳、史麗珠、莊逸洲（2001）。某醫學中心一般外科住院醫師臨床醫學訓練時間分配之探討。台灣公共衛生雜誌，20(3)，228-237。https://doi.org/10.6288/TJPH2001-20-03-08
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- 楊雅涵（2009）。Renovation of Prescribing Error Reporting System and Analysis of Inpatient Prescribing Errors in a Medical Center〔碩士論文，國立臺灣大學〕。華藝線上圖書館。https://doi.org/10.6342/NTU.2009.02413