病歷寫作 (二)

                                                                   

許清曉醫師  2005-8-31

上接『 病歷寫作（一）』

7. Procedure Note (任何病歷上的紀錄，都要寫明日期時間)，舉例如下：

                                             i.                Procedure done: spinal tapping

                                           ii.                Indication: To rule out CNS infection; eye ground showed no signs of increased ICP, and cranial CT showed no mass.

                                          iii.                Consent form obtained after thorough explanation to the patient in the presence of RN Chen YJ and the patient’s mother

                                         iv.                Patient was laid on his left lateral side in fetal position

                                           v.                Local anesthesia with 2% Xylocaine, 5 mL.

                                         vi.                22 G spinal tap needle was inserted through the space between L3-L4 without problem

                                        vii.                CSF: crystal clear; 2 mL each, was withdrawn into four tubes. One sent for antigen studies (…), culture, and smears; one sent for chemistry; one for cell counts; and the last one for STS/VDRL.

                                      viii.                OP:  110 mmHg; and CP: 100 mmHg

                                         ix.                There was no complication and the patient tolerated the procedures well.

                                           x.                The patient was instructed to lie on his back for 8 hours.

                                         xi.                Simultaneous blood sugar has been drawn

8. 給週末或假期接班人看的摘要

Weekly summary應該要能讓讀者幾分鐘內就很快的瞭解病人住院後迄今病情、可能發生的問題，可以讓值班醫師很快就進入狀況，知道這週末要特別注意什麼。內容需：

                                             i.                簡單扼要

                                           ii.                說明這次住院經過

                                          iii.                問題解決的程度

                                         iv.                目前如何處理中

                                           v.                這幾天內有可能發生的問題，要請值 班 醫師特別注意的問題

                                         vi.                可聯絡到我的電話號碼

舉例如下：

This 72years old man was admitted on 2004-12-5 , because of melena for 2 days prior to admission.  Endoscopy revealed active bleeding ulcer on the duodenum.

Packed RBC 8u was given after admission because of 7.8 gm % Hgb.  Follow-up Hgb was 11.2 gm %.  Tarry stool has stopped now.

PPI (Losec 1 amp iv bid) was shifted to oral Nexium 1# qd on 2005-12-10 .  General condition is stable now.

He will be kept under close observation, and discharged next Wednesday (Dec.14), if clinically unchanged.  He will be followed up at G-I clinic (Dr. C.Y. Lee, Wednesday afternoon) after discharge

  也可以簡單地寫為：

72 y.o. man, admitted on 2004-12-4 for melena.  Endoscopy: active bleeding ulcer of duodenum.

[也可以更簡單地寫： 72 y.o. man, admitted on 2004-12-5 for bleeding duodenal ulcer.]

Packed RBC 8U for Hgb of 7.8gm %.  Follow-up Hgb= 11.2 gm %.  No more tarry stool.  On oral Nexium, after PPI (Losec), iv.  Condition stable.  To be observed closely.  Triple anti-Helicobacter therapy begun.  To be discharged tomorrow and followed-up at GI clinic, if stable.

 

9. Discharge Summary

近來越多的出院摘要以電腦張貼admission note, lab data, x-ray report, pathology report等方式貼程成為很長的『摘要』，都不是適宜的。『出院摘要』應該是經過整理的資料，應該能夠很快地看出住院中主要的過程，也要包含不一定有關病程但和病患健康相關、重要的檢查數據。

10. 哪些是新制評鑑中新增病歷寫作項目？

這些是以前沒有要求的病歷書寫內容，但強調醫療品質的時代，這些都要寫清楚：

•         3.2.1.1應向病人適當說明病情及治療方式、特殊治療及處置，說明內容應有紀錄

•         5.2.1.2評估並記載病人住院時之身體上、心理上，及社會上的狀態

•         5.2.1.3應將病情及住院理由向病人說明，並記載在病歷中

•         5.2.2.1製作完整且適當之住院診療計劃

•         5.2.2.3訂定出院照護方針及計劃

•         5.5.1.1手術前應有相關討論，檢討手術方法，並選擇最適當的手術方式麻醉、處置之選擇亦有檢討上列各項均記載於診療紀錄內

•         5.5.1.3手術與麻醉方式及其優缺點、手術以外之其他替代方案應向病人詳盡說明並簽署手術及麻醉同意書

11. 如何在病歷記載感染相關資料，以免抗生素費用被健保剔退？

抗生素費用是健保刪除費用中的最主要項目，因為往往審 查 醫師沒有能夠從病歷上的描寫，瞭解病況的嚴重性，而致藥物費用被剔退，結果主治醫師以後不知如何給藥，病患常常未能接受該用的、較昂貴的藥物，以致病情拖延，浪費醫療資源，甚至使病情惡化。其惡果更甚於不良的病歷寫作。

l          呈現感染確實存在，必須經驗性使用抗菌藥。

                                                             i.                WBC異常增加。（有感染也不一定會增加）N:L (neutrophil to lymphocyte) ratio

                                                           ii.                CRP異常增加。

                                                          iii.                有發燒。（有感染也不一定會發燒）

                                                         iv.                有其他症狀：例如咳嗽、濃痰、呼吸急促、 等等

                                                           v.                有徵候： rales, redness, tenderness, swelling, etc

                                                         vi.                其他：CXR、 U/A、CSF、aspirates、培養等的檢驗結果如何？

                                                        vii.                照相、繪畫！！

l          每一、兩天詳細描寫徵候、症狀、數值的升降，改善惡化。

l          用抗生素者，至少每五到七天記載需要繼續用藥的理由。

l          換用抗生素者，一定要寫換藥的理由。

12. 預防性、管制性、非管制性、及門診的抗生素使用都要合理地說明

以前並沒有強調『在病歷上書寫使用抗生素之理由』的重要性。如今不論什麼類的抗生素，該用就要用，需用才用。但是要寫明為什麼用？尤其，較狹效的、較舊的、較便宜的非管制性抗生素，如果使用在重症ICU病患，應該說明為什麼使用治療效果較差的藥物、讓病患迅速治癒的機率偏低？明顯的急性感冒為什麼要用抗生素，必須說明；預防性抗生素的使用沒有照規定，例如使用過久或劑量過低，應該說明；輕度感染為什麼要用上廣效的、較昂貴的、較新的管制性抗生素，要說明。

13. 常見的錯誤的或不適宜的英文

以下列舉的，是最常見的需改正的『病歷英文』，都是已成為台灣病歷內『制式』錯誤的詞句：

                                                             i.                Cancer was told （主詞錯了！），應改為Cancer was suspected 或 detected或discovered或diagnosed 。或 “Cancer”, he was told.(小說式的)

                                                           ii.                The patient went to an LMD in vain。（病人並不是去醫師處沒有成功，並沒有迷路），應該寫the treatment was not effective; 或 the symptoms did not improve .

                                                          iii.                The patient ever went to a hospital 應改為The patient has been to a hospital.  The patient did go to a hospital.

                                                         iv.                Acception note （字典沒這個字），應改為acceptance note, 或 on-service note.

                                                           v.                Progression note，progressive note應改為 progress note .

                                                         vi.                Cancer was impressed應改為 Cancer was suspected .

                                                        vii.                Conscious clear. 應改為Consciousness: alert, coherent and oriented as to time, place, and person (常簡寫成 oriented x 3)

                                                      viii.                Discharge diagnosis: R/O cancer （出院診斷這麼寫，讓人不知是否已排除了cancer？），應改為probable cancer、suspected cancer。

                                                         ix.                會診單上寫完意見之後自己寫 Thank you for the consultation （consultation是自己寫的部分，這句似是自己感謝自己的意見！），應改為Thank you for the referral，或只寫Thanks.

                                                           x.                Nothing particular. (N P) 應改為 unremarkable。

                                                         xi.                Unfortunately （可免寫）, abdominal pain and high fever developed。（病人生病我們醫護人員都很難過，但病歷是寫病人的病情、感受，而不是要發洩醫師百感交集的情緒！）

                                                        xii.                Dear Dr. ;  We sincerely request……;  your nationally reputable expertise…. Your globally acclaimed technical skills : 太肉麻，都可免寫，多記載病史、檢驗數據。

                                                      xiii.                According to the statement of the patient應改為 according to the patient; according to his sister。

                                                      xiv.                The patient is a victim of motor vehicle accident (MVA). 應改為可寫成 The patient had an MVA。

                                                       xv.                MBD (may be discharged) （似是主治醫師在推諉出院的責任），應改為 discharge; discharge in AM。

                                                      xvi.                AAD 應改為 discharge against medical advice; discharge AMA。

14. 英文簡寫

•         因為英文術語越來越多，發音也不容易，結果使用簡寫的越來越多，（台灣很多簡寫也不合一般簡寫的規律，例如meta, anti, on endo），導致很多紀錄會令人誤解，或看不懂。因此各國醫界都有少用簡寫的呼聲，不過醫用簡寫在各專家之間、各次專科之內使用，實在也難嚴格禁止。可能較適當的使用簡寫的限制是，尤其在admission note, discharge note, consultation notes, summary notes, operation notes等眾人會看的紀錄上，僅可使用檢驗項目及在醫學院 時就 教授的簡寫。如有必要，則在病歷的各種記錄上第一次使用時，先用全名，在後面括弧內補註簡寫，以後在同一記錄內都用簡寫。所用縮寫也應該使用三個以上的字母，且合乎縮寫的通則。例如：anti (antibiotics?)宜寫為atbx； meta (metastasis?)宜改為mets； on endo應該是intubated。特別容易誤解的 qd, 及qid，建議都不使用，分別改為 once a day 或 once daily，及four times a day。

 

 

u        結語

迅速改正缺點，使病歷內容達到能夠『一目瞭然』、『簡潔、完整』的要領，就是TPR sheet要詳細填寫、病程記錄的assessment每天要有醫師對病情的仔細評估記載。其他admission note, weekly summaries, discharge summary都不能有抄捷徑的觀念，該由醫師仔細評估的還是要由醫師確實認真地去檢查思考。關鍵還是在於主治醫師要負責做好該做的事。

病歷書寫如果每天寫慣了，其實也不難，熟能生巧，病情評估的思路自然會很通順。下筆、打字都可以很快。一開始，可以一天仔細思考如何記載一個病例的progress note，以後每天加一個，到每天每本病歷都有當天的病程紀錄為止。如此，看每位醫師寫作的天分，內容還可以逐漸進步，簡潔、完整。負責的病患人數實在太多，無法做完工作，就不應該收治那麼多，以致降低醫療品質。

台灣的病歷寫作，問題不少，以上列舉的是共通的毛病。這些問題似乎多年來持續存在，已是積數十年的陳疾，不是一朝一夕可以改變的。但是實際上很多醫師是想做好本分的工作；『專科護理師』、『臨床技師』也是很期待有更好的訓練，讓她們的工作能受到讚賞；對病歷寫作關心的專家前輩也都希望有各種指引或課程，以便醫師們趕快學習正確的病歷書寫。

只要衛生單位的醫療部門長官、各醫院的主管，決心全面徹底地推行教學及查核效果，強調從重點開始先改起，再附加獎懲辦法，必定能在短期內有顯著的進步。近兩年來衛生署醫策會及醫療品質協會積極著手教育如何確實改善病歷寫作的內容，再繼續做實際病歷的修改示範。如果能夠持續，重複不斷的研習，先從關鍵性的錯誤開始著手修正，再逐漸擴展到細節，並配以後續的成效查核，應該是兩三年內就會有大幅的的改進。

 

參考資料：

一、        病歷書寫參考指引。范碧玉等主編，2005年，合記圖書出版社

二、        許清曉，王立信，王任賢，楊祖光：Propriety of the Use of Antibiotics for Hospitalized Patients in Taiwan。臺灣住院病患抗生素使用適當性及相關問題的調查結果。院內感染控制雜誌NICJ 2001﹔11﹕273-88

三、        許清曉：抗生素的使用如何管制？感染控制雜誌ICJ 2005; 15: 81-7

 

Abstract

The quality of medical records in Taiwan has deteriorated alarmingly over the last 30-40 years.  The reasons include attending physicians that are too busy to write patient records and that are not that familiar with the English language and therefore avoided writing.  English is being promoted in Taiwan as the language to be used in medical records because it is the international language for science and medicine.  As the first step in improving the content of the records, the author encourages the doctors to employ clauses or phrases, omitting subjects or verbs in most of the sentences in these records, and write without fear of making grammatical errors.

There are four major deficits in our medical record writing that should be remedied immediately.  (1). Main medications, key test results, and other important events during hospitalization should be charted in the TPR sheet.  This will allow the hospital course of the illness to be illustrated clearly in the TPR sheet.  (2). Problem-oriented medical records (POMR) are a better way than the S.O.A.P. to organize the daily clinical progress and the plan of management.  The doctor must provide his/her assessment of the patient’s response to the therapy.  (3). More detailed history taking and physical examination should be performed.  This should quickly point the doctor’s diagnostic and therapeutic efforts in the right direction.  (4). Computerized patient records will make things easier.  However, copying and pasting of the same records made previously, as has been done widely, should be avoided.

Other items, such as digitized photography for visible lesions, weekly summaries, the discharge note, stating the reasons for prescribing antibiotics in the progress notes, reduction of the use of abbreviations, and correction of certain errors in English, etc, all need to be improved or implemented as soon as possible.

 

（下接另一篇： 病程記錄書寫的改進意見）