口述錄音聽打作業在醫院病歷品質角色上的探討

A Study on the Roles of the Medical Transcription in the Quality of Patient Records

聽打系統起自美國的1960年代，目的在改善病例的書寫完整性及清晰易讀性。醫師之生產效率可提升3.8%，醫師書寫病例的附和會影響病例的完整及正確性，聽打可以改善此現象。若考慮到醫師的時間節省，則聽打的成本就不會被高估了。目前國內醫師對敘述性病情，除自行逐字將病例輸入電腦，或藉由不完整的點選輸入系統外，多半是藉助手持類比型錄音帶方式進行病例聽打作業，其周轉時間長、錄音帶交換也麻煩，而電話語音的聽打系統則可節省其錄後至聽打完成的時間。中央健保局未來審查給付之依據必定走向『DRGs品質審查之監控模式』。總額制度下將病例描述清楚，以供編制正確的ICD碼，獲取合理的給付。

The purpose of this paper is to explore a possible suggestion for hospitals under global budgeting for the Taiwanese health care system to implement the patient records digitalized. After conducting a survey sampling 30 big hospitals and 337 physicians about the views of dictation and the Global Budget Payment System. We concluded that over 80% of them agreed to the talking more complete than the handwriting. About 51% considered dictated notes helpful to physicians. The 59% physicians recognized dictation upgrading to chart quality. Of these 337, more than 250 typing word per minute are below 30 in this research. It is too difficult for physician personally to type narrative patient record into computer. The legible, readable, and concise medical records are correctly coded to comply with the upcoming DRGs reimbursement in Taiwan. Replacing the process of analog tape and setting up a Dictaphone through internet in ChiMei hospital, we addressed that the 'what you say is what you soon get' on phones has reaped on the turnaround time saving from days to hours and the complete medical records being gotten. The paper suggests adopting the Wed-based Dictaphone system to help the physicians dictate their unstructured patients' records to be transcribed as text files. As global budgeting is meant the entirety of the information systems used to monitor the performance of the health care financing and delivery system, and the associated regulatory processes by which health spending is controlled and allocated. We urgently recommend that a fully computerized patient records system should be coped with the features of 'VOICE...to TEXT...to DATA...to KNOWLEDGE'. If so, the ideal of 'The electronic medical record. Good-bye paper charts, hello better patient care.' could be realized completely.