提昇住院醫師病歷紀錄品質教學活動之探討

A Study on Improving the Quality of Residents’ Medical Records through Continuing Education

目的：醫療院所持續規劃及推動病歷教育，對提昇住院醫師病歷紀錄品質具有正向的助益。本研究深入探討各項教學活動與病歷紀錄品質之間的關聯性，回饋教學單位做為規劃住院醫師病歷書寫教學活動之參考。
方法：以各職級住院醫師為對象，辦理「Admission Note 病歷寫作比賽」活動，除針對住院病歷表單書寫要項授課外，並以預製教學影帶播放方式進行寫作比賽，經由分組評核結果呈現不同職級醫師於該表單待強化處，同時透過問卷瞭解住院醫師對各項教學活動的認知與看法。
結果：住院醫師參與者計有98 位，扣除外調輪訓等人員，與會者超過各科住院醫師50% 以上。比賽結果「Admission Note 之Impression」為表單紀錄相對較弱部份；住院醫師第一年及第二年Plans 亦有待加強。問卷結果，有效回收率95.9%，其中「工作太忙（57.4%）」及「英文敘述表達（29.5%）」為造成病歷書寫欠缺完善及最需加強者。最能提昇病歷紀錄品質教學活動為「病房迴診床邊教學（39.4%）」、「各式病例討論會（20.4%）」等；最有效益教學方式為「個別病歷指導（39.0%）」、「小組教學（27.1%）」等。
結論：病歷教學活動對提昇病歷紀錄品質是有助益的，更仰賴主治醫師用心指導住院醫師改善病歷紀錄缺失。建議管理部門重視臨床醫師工作負荷對病歷品質的影響，規劃多元化共通性與個別性課程時，酌予增加主治醫師「病房迴診床邊教學」、「個別的病歷指導」及「指導英文病歷書寫」等活動，輔助各職級住院醫師照護病患同時學習掌握書寫重點；提昇醫囑系統可近性並指導臨床醫師善加利用、強化病歷審查系統雙向溝通功能。以多樣化教學模式協助住院醫師克服書寫困境，進而達成提昇病歷品質的目的。

Objective: It has been shown that continuing education about medical writing has a positive impact on the quality of medical records. The aim of this study was to understand the association between teaching programs and the quality of medical writing. We included residents’ learning needs, teaching pathways, and relevant feedback as elements in the design of a future course.
Methods: Our program included basic teaching about admission notes, a writingcontest after a simulated videotaped admission, and a questionnaire for attending physicians.
Results: A total of 98 trainees, i.e. more than half of the hospital residents participated in this teaching-writing program. In the writing test, the quality of the item “impression” was generally unsatisfactory. Junior residents (R1 and R2) showed some difficulty in setting up admission “plans”. Daily workload and English writing ability were cited as the main reasons for unsatisfactory medical writing. Teaching activities including bed side teaching, case conferences, and personal or small group teaching were listed as better modalities to promote powerful medical writing.
Conclusions: Encouraging teaching staff to place a special emphasis on chart writing during medical rounds may help residents improve their writing ability. For better medical writing, the residents’ workload should be adjusted and the teaching program designed to include individualized English writing activities. Further improvement in the electronic medical ordering system, reinforcing the review of medical records, and more diversifi ed teaching activities may also improve the quality of medical records.