臨床照護計畫認證病歷紀錄審查概要

All about CCPC and Medical Record Review

CCPC（Clinical Care Program Certification）臨床照護計畫認證是JCIA（Joint Commission International Accreditation, JCIA）評估及認證醫療機構對特定疾病患者之治療及服務程序之標準，其對病歷紀錄之要求乃以JCIA為基礎，相關規範及審查方式亦比照JCIA，然由於特殊疾病之收案、評估、衛教…等紀錄有其特殊性，除了病歷中之單張須依循JCIA規範紀錄與保存外，其衍生出由單位留存之各類單張、紀錄亦須符合JCIA之要求，包括病歷格式之統一、資料之隱私保護、病歷安全、符合院內縮寫政策及內容之完整…等，準備過程中，配合評鑑推動中心規劃之Closed Medical Record Review預評，確認該計畫之病歷紀錄及管理均符合CCPC之要求。 CCPC (Clinical Care Program Certification) is a standard created by JCIA (Joint Commission International Accreditation) to evaluate and certify medical institutions for their treatments and services provided to patients with specific diseases. The requirements for establishing medical records are based on JCIA principles, and the relevant rules and survey methods are also determined by JCIA. However, as the records of the enrollment, assessment, education, etc. of special diseases are particular in nature, the medical records must be recorded and preserved according to the JCIA standards. Any records kept in clinical unit must be preserved in compliance with the requirements of JCIA, including the uniformity of medical records format, the privacy protection of medical information, the safety of medical records, the compliance with hospital abbreviation policies and the completeness of the content. Within the preparation period, the staff members must make sure the records' content and management comply with the requirements of the CCPC by the Closed Medical Record Review pre-assessment.