出院病歷行政作業之流程改善

Improvement on Administrative Procedure of Inpatient's Medical Record at the Time of Release from the Hospital

10.29741/JMHIM.201006.0003

張菁育(Ching-Yu Chang)；林玲珠(Ling-Chu Lin)；陳星助(Hsing-Chu Chen)

病歷審查 ； 醫院評鑑 ； 出院病歷行政管理 ； Medical Records Review ； Hospital Accreditation ； Medical Record Administration

病歷資訊管理

9卷2期（2010 / 06 / 01）

37 - 50

繁體中文

縮短出院病歷完成時間，爲醫院評鑑及健保申報重要指標之一。本院歷經評鑑後發現病歷完成率與病歷組及醫護同仁的密切合作有闕，經收集資料發現出院病歷行政作業時間之長短與病歷完成時效相關性大，再深入分析可得知病歷審查作業流程的調整能夠有效提升病歷的完成率，因此在病歷組人力維持不變下進行作業流程改善，透過單位同仁主動出擊至各病房進行病歷審查。 本院自2009年6月開始進行專案改善，透過品管圈的手法進行作業流程調整，執行後成效良好，其中出院病歷行政作業時間從2.96天縮短至0.84天、平均完成天數也從3.41天降低至2.08天，而調金醫護同仁之滿意度也高達85.75%，可呈現專案的執行提升醫護同仁的自我管理，促使本院病歷完成率明顯進步，同時加強跨單位合作的溝通與效益，進而讓本院符合評鑑規定及申報資料檢附的品質。

How to minimize the time needed to complete an inpatient's medical record after his/her release from the hospital is one of the important indicators in hospital accreditation as well as National Health Insurance claims. After a recent hospital accreditation, one of our findings is that medical record completion rate is somewhat closely related to the cooperation of the attending health care team and medical staff involved. Based on our collected data, it's also realized that time spent on administrative process of the inpatient's records operation is a prominent determinant that can improve the completing rate of medical record. A follow-up and deeper analysis revealed and suggested that modification of the medical record review process would most effectively cut down on the completion time. Therefore, we conclude that if we choose routinely going out to review medical records on-site at the wards instead of waiting for them to be sent over will definitely shorten the completion time and get the improvement without adding extra manpower to the existing Medical Record Office. NTUH has implemented such an improvement project since June 2009, which was an adjustment of workflow through the means of quality control circle. The outcome of the implementation is rather good. The achievements include: the administrative operation time spent on the medical record process of an impatient re leased from the hospital has been shortened from 2.96 days to 0.84 days, the average completion time also shortened from 3.41 days to 2.08 days, and the medical staff's satisfaction rate has increased to 85.75%. These figures represent that the project has indeed enhanced the self-management ability of members of our healthcare staff and resulted in significant progress in the rate of medical record completion. At the same time, it reinforced the communication among and efficiency of individual departments that further a\low NTUH to fulfill the hospital accreditation requirements and attain the quality suited for the claim data.