北部某區域教學醫院實施病歷無紙化過程之探討

On the Implementation of Medical Records with No Paper at a Certain District Teaching Hospital in Northern Region

為落實衛生福利部「全人健康照護」政策目標，自民國99年7月起實施電子病歷進行電子簽章，並朝向無紙化目標前進。在實施電子病歷期間產生效益包含病歷表單實施電子簽章逐年增加；門診全面不調病歷，必要時才調；至今已減少5個人力；每年檔區加班費減少10萬元支出；每年減少24萬3千元紙張費用支出；外傷照片全面上傳PACS系統，健保抽審全面採數位化抽審減少人力成本；電子病歷互通及下載數也逐年增加。另外住院病歷護理資訊系統亦逐步朝向電子簽章無紙化方向。實施無紙化過程產生效益涵蓋節省翻閱病歷加速診療、避免重複檢查、避免重複用藥、儲存紙本病歷的空間也可節省，更可達到節能減碳、減少調閱病歷人力及達到院際間資訊整合。

Since July 2010, in order to help facilitate the 'Healthcare for All' policy of the Ministry of Health and Welfare, the making of our medical records have been gradually shifted into the electronic version. Starting with electronic signatures, the project moved on towards a final paperless goal. Efficacies resulted from the implementation of electronic medical records Included increases year by year in numbers of medical records formed with electronic signatures; our outpatient clinics totally stopped providing medical records on-site as a routine, except when absolutely necessary, which has enabled us to cut back manpower need by 5 workers; plus annual savings reached up to NT$100,000 in overtime payments, and NT$243,000 in paper expenses; trauma photos were fully uploaded with PACS system, along with the selection of sampling examination of health care insurance cases was fully digitalized to reduce labor costs; and the number of electronic medical record exchanges and downloads were steadily on the rise over the past years. In addition, both in-patient medical records and nursing care information system have been gradually evolving into something with electronic signatures and advancing in the paperless direction. The benefits of implementation of such paperless effort included significant time saving realized in consulting this new type records and consequently speeding up the diagnosis and treatment processes that follow, being able to avoid wasteful duplications of checkup and medication, saving vast space needed for storage of the bulk paper records, fulfilling the new trend of energy saving and carbon reduction requirements, plus cutting back more manpower necessary for the access to the old type paper records and facilitate the Integration of information among hospitals.