運用跨團隊合作提升專科護理師住院病歷書寫之完整性

A Cross Team Collaboration Project for Improving the Integrity of Nurse Practitioner Writing Medical Records

10.29494/LN.202012_21(4).0008

鄭沛綾(Pei -Ling Cheng)；林莠美(Yu-Mei Lin)；李千佩(Chian-Pei Li)；陳芝文(Chih -Wen Chen)

跨團隊合作 ； 專科護理師 ； 住院病歷書寫 ； cross team collaboration ； nurse practitioner ； medical records

領導護理

21卷4期（2020 / 12 / 01）

103 - 117

繁體中文

病歷提供醫療服務者訊息傳達與溝通的工具，團隊可透過病歷短時間內即能知悉病情並提供醫療照護，完整的病歷可呈現醫療成效。臨床上發現專師花費許多時間在病歷書寫，內容過於簡化且常有遺漏，經現況分析確立原因為病歷書寫標準規範簡略、缺乏可參考的病歷書寫範本及教案、缺乏醫護英文課程、電腦介面不友善費時、缺乏獎懲制度。經由修定病歷書寫標準規範，依專科性制定病歷書寫範本及教案、舉辦醫護英文課程、推行住院病歷書寫電子化、病歷書寫介面改版、於電腦資訊系統建立病歷書寫常用片語及範本、建立獎懲制度後，病歷書寫完整性由56%提升至85%達改善目的，藉由清楚且詳實的病歷記載，了解病人的治療計劃，更可作為學習、研究及教學之參考。

The medical record provides a tool for information transmission and communication of the medical service providers. The team gets to know the condition and provide medical care through the medical record in a short period of time, and the complete medical record can show the effectiveness of the medical treatment. Clinically, it is found that the specialists spend too much time writing the medical records. The content is too simplified and often falls short. The analysis of the current situation has established that the standard of medical records is plain; the medical records and teaching plans lacking references; insufficient medical English courses; and the computer interface are not friendly; time-consuming, and inadequate reward and punishment system. Through the revision of medical record writing standards and specifications, the preparation of medical record writing templates and teaching plans are developed according to the specialty area; the establishment of medical English courses, the implementation of electronic writing for medical records in hospitals, the revision of medical records templates interfaces in computer information systems, and the establishment of rewards and punishments. After the system implementation, the integrity of the medical record has improved from 56% to 85%. The clear and detailed medical records can be used to understand the patient's treatment plan, and also serves as a reference for learning, research and teaching.

1. 方淑珍,黃玉梅,郭雅菁,許翠華(2016)。以跨團隊合作縮短STEMI病人接受心導管治療術時間。志為護理─慈濟護理雜誌，15(1)，70-83。
   連結：
2. 林惠娥,李建德,曾昱龍,林新景,李逢君,陳明志,林威宇,黃秋慧,劉家壽(2013)。提升住院醫師病歷紀錄品質教學活動之探討。醫務管理期刊，14(3)，244-267。
   連結：
3. Bormel, J.(2011).Problem lists are the keys to meaningful use.Health Management Technology,32(2),40-41.
4. Buchanan, J.(2017).Accelerating theBenefits of the ProblemOriented Medical Record.Applied Clinical Informatics,8(1),180-190.
5. Ham, P. B.,Anderton, T.,Gallaher, R.,Hyrman, M.,Simmerman, E.,Ramanathan, A.,Howell, C. G.(2016).Development of ElectronicMedical Record-Based "Rounds Report" Results in Improved Resident Efficiency, More Time for Direct Patient Care and Education, and Less Resident Duty Hour Violations.The American Surgeon,82(9),853-859.
6. JCAHO. (2010, January 1). National Patient Safety Goals. Retrieved May 1, 2010, from http://www. jointcommission.org/PatientSafety/National Patient Safety Goals.
7. O'Donnell, H. C.,Kaushal, R.,Barrón, Y.,Callahan, M. A.,Adelman, R. D.,Siegler, E. L.(2009).Physicians' attitudes towards copy and pasting in electronic note writing.Journal Of General Internal Medicine,24(1),63-68.
8. Simons, S. M. J.,Cillessen F. H. J. M.,Hazelzet, J. A.(2016).Determinantsof a successful problem list to support the implementation of the problem-oriented medical record according torecent literature.BMC Medical informatics and Decision Making,16(102),1-9.
9. 王曼蒂,楊淑慧,宋佳穎,劉淑芳,陳碧蓮(2010)。影響護理人員使用護理紀錄標準化範本之相關因素。榮總護理，28(3)，241-248。
10. 周登偉,賴芳足,李秋慧,徐華吟,葉淑如,呂錦慧,林佩勳(2013)。導入團隊資源管理對加護單位病人安全文化之影響。醫院，46(4)，32-41。
11. 林小娟,周子昌,許淳森,李隆熙,邱濬昇,張毓仁(2010)。JCI評鑑與病歷紀錄品質。病歷資訊管理，10(1)，1-11。
12. 范姜玉珍,楊慧貞(2012)。共創同心圓探討護理同仁與醫療團隊的合作。志為護理─慈濟護理雜誌，11(2)，16-19。
13. 張菁育,林玲珠,陳星助(2012)。建立病歷摘要中文化範本-以五種診斷為例。病歷資訊管理，11(1)，7-21。
14. 張靜怡,徐德福,張韻勤,陳品堂,徐月霜,劉秀薇,傅玲(2012)。某醫學中心護理人員對單位醫療團隊資源管理現況感受之初探。榮總護理，29(4)，405-413。
15. 許淑玲,李淑靖,蔡慧貞,蔣維凡(2013)。以品管圈手法提升病歷書寫完成時效。病歷資訊管理，12(1)，19-30。
16. 黃怡菁,賴淑芬,高源忠,孫茂勝(2009)。某醫學中心住院中病歷品質改善實務。病歷資訊管理，9(1)，1-17。
17. 褚惠瑛,張菁育,林玲珠,邱聖豪,陳星助(2013)。電子化病歷品質審查系統之建置。病歷資訊管理，12(1)，31-45。
18. 劉建財,許明輝,楊沛墩,馮容莊(2012)。台灣醫療機構實施電子病歷之探討。領導護理，13(2)，2-11。
19. 蔡蕙鍾,王春葉,林耀信,李建德(2014)。以品管圈手法提升血液透析護理紀錄之完整率。病歷資訊管理，13(1)，19-34。

1. 蔡沁筠(Chin-Yun Tsai);賴甫誌(Fu-Chih Lai);凌旺楨(Wang-Chen Ling);陳柏安(Bor-An Chen);李筱薇(Hsia-Wei Lee)(2022)。由護理學生觀點探討全英語教學在災難護理教育的運用。榮總護理。39(4)。412-420。