運用結構化電子病歷表單提升侵入性檢查處置紀錄書寫品質之實務經驗

Improving the Quality of Invasive Procedure Note Documentation Through Structured Electronic Medical Record Forms: A Practical Experience

目的：侵入性檢查之處置紀錄（procedure note）屬醫療法定文件，內容涵蓋操作步驟、使用器械與藥物等關鍵資訊，其完整性對臨床決策、醫療團隊溝通及病人安全具有重要影響。然而傳統紙本紀錄常因欄位不明確或缺乏提醒機制而導致遺漏。本研究旨在評估導入電子化病歷表單系統後，對處置紀錄書寫完整率之成效。
方法：
本研究盤點院內所有侵入性檢查項目，並與臨床團隊共同制定標準化作業流程。同時建置電子化處置紀錄表單，整合預設範本、欄位鎖控與醫囑綁定（order binding）功能，並設計自動提醒與未完成紀錄通知機制。依導入進程分三階段比較：紙本／非結構化書寫、標準化範本與Time-out提醒、電子化系統全面實施。
結果：
在紙本作業期間（2023年第1、2季），處置紀錄完整率為41.2%。導入標準化範本與time-out提醒後（2023年第3、4季），完整率提升至56.4%。2024年全面建置院內電子系統後，完整率大幅提升至94.4%，並於2025年達到99.1%。
結論：
將處置紀錄以結構化方式電子化，並將書寫行為與醫囑流程緊密整合，可顯著強化紀錄完整性與時效性。自動化提醒減少人為遺漏，提升病歷品質與病人安全，並提供更可靠之資料來源以支持後續醫療品質管理。

Purpose: Procedure notes are essential medicolegal documents that detail the steps, instruments, and medications involved in invasive procedures. Their completeness directly influences clinical decision making, interdisciplinary communication, and patient safety. However, traditional paper-based documentation is prone to omissions due to inconsistent formats and the absence of reminder mechanisms. This study aimed to evaluate the impact of implementing an electronic medical record (EMR) form, integrating structured templates, mandatory fields, and automated alerts, on the completeness of procedure note documentation.
Methods: All invasive procedures requiring procedure notes were systematically inventoried, and standardized documentation requirements were established in collaboration with clinical teams. A structured electronic procedure note form was subsequently developed with preset templates, field locking functions, and an order binding mechanism that links documentation tasks directly to procedure orders. Automated prompts and incomplete record notifications were incorporated to ensure timely documentation. The study employed a three-phase comparative design: (1) paper-based or unstructured documentation, (2) standardized templates with time out–based manual reminders, and (3) full implementation of the integrated EMR system.
Results: During the paper-based phase (2023 Q1–Q2), the completeness rate of procedure notes was 41.2%. After introducing standardized templates and time out reminders (2023 Q3–Q4), the rate improved to 56.4%. Following the full deployment of the electronic system in 2024, documentation completeness increased markedly to 94.4%, reaching 99.1% in 2025.
Conclusion: Implementing a structured electronic procedure note form, combined with workflow integrated order binding and automated reminders, significantly enhances documentation completeness and timeliness. These system-based controls reduce human error, strengthen medicolegal documentation quality, and provide reliable data to support ongoing quality improvement initiatives and patient safety efforts.