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研究生:施慧明
研究生(外文):Hui-Ming Shih
論文名稱:醫師特性與病歷完成率之相關性研究-以雲林某地區教學醫院為例
論文名稱(外文):The Correlation study between the characteristics of physicians and medical record completion rates – taking a teaching hospital in Yunlin County as an example
指導教授:古東源古東源引用關係
指導教授(外文):Tong-Yuan Koo
學位類別:碩士
校院名稱:國立雲林科技大學
系所名稱:健康產業管理研究所碩士班
學門:工程學門
學類:工業工程學類
論文種類:學術論文
論文出版年:2013
畢業學年度:101
語文別:中文
論文頁數:47
中文關鍵詞:醫師特性病歷完成率
外文關鍵詞:medical record completion ratesPhysician characteristics
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目的:
本研究旨在探討醫師特質是否會對病歷完成率有所影響,以供各醫療機構參考,有效提升病歷完成率。
方法:
採回溯性資料收集雲林縣某地區教學醫院自99年至101年之出院資料,主要是利用該院病歷室每月所產生之未完成病歷統計報表進行分析,未完成病歷統計報表內之欄位包括:病人病歷號、姓名、床號及住出院日,主治醫師姓名及科別,以及病歷應完成日等相關欄位;以單因子變異數分析,了解醫師科別是否會影響病歷如期完成的比率。以線性迴歸模式,分析醫師服務量對病歷如期完成率是否有顯著差異。再以獨立樣本t檢定,分析醫師性別對病歷如期完成率是否有影響。
結果:
醫師科別與病歷完成率的關係是顯著的(P=0.15),且在多重比較的分析之下,外科系是優於內科系的;醫師服務量與病歷完成率是呈現負顯著,也就是說醫師的服務量愈高,其病歷愈不容易如期完成;醫師性別與病歷完成率也是有顯著的差異,且男性主治醫師的病歷完成率是高於女性主治醫師的。
結論:
醫師特性(科別、服務量多寡以及性別)皆會影響病歷完成率的高低,針對內科系病歷完成率較外科系差的情況,建議院所可針對內科系常見病歷須書寫內容設立電腦套餐方式,讓醫師人工手寫作業可以化到最簡,病歷內容亦可完整呈現。另外,服務量多的醫師病歷完成率也較低,建議醫療院所日後針對服務量較高的科別可以規劃協助人力,讓醫師有更多時間可以完成病歷繕打,提升病歷完成率。
Objective:
This study explores whether physician characteristics affect medical record completion rates for offering the reference of various medical institutions to enhance medical record completion rates.
Methods:
By collecting and mining the retrospective hospital discharge data from 2010 to 2012 in a regional teaching hospital in Yunlin, mainly the incomplete medical records of monthly statistical report for analysis in the hospital room, including patient medical record number, name, number and discharge date, attending physician''s name and department, medical record completion date and other related fields to process the analysis.
By employing single factor analysis of variance to figure out whether physician divisions would affect medical record completion rates.
By using a linear regression model to analyze whether physician services apparently influence medical record completion rates.
By taking the independent sample t test to analyze if the physician gender impacts on the medical record completion rates.
Results:
The relationship between physician divisions and medical record completion rates is significant (P=0.15), and under multiple comparison analysis, department of surgery is superior to the department of internal medicine on the performance of medical record completion. Physician services have remarkable negative influence to medical record completion rates; that is, the more physician services are offered, the less medical records are completed. Besides, physician gender significantly affects the medical record completion as well; and the volume of physician medical record done by male attending physicians is higher than the ones done by the female attending physicians.
Conclusions:
Physician characteristics (division, volume of service, and gender) will affect the performance of medical record completion rates. To solve the issue that medical record completion rate of the department of internal medicine is relatively lower than the one of department of surgery, the writing computer package, which is able to present the complete content of the anamnesis and simplify physician’s hand-writing job on the medical record of internal medicine department for common diseases, is recommended.
In addition, as the physician whose service volume is higher shows lower medical record completion rate, more human resources provided by the health institutes for the departments presenting higher service volume are recommended to enable physicians to have more time completing case history and upgrading medical record completion rates as well.
中文摘要------------------------------------------------------------i
英文摘要----------------------------------------------------------iii
誌謝----------------------------------------------------------------v
目錄---------------------------------------------------------------vi
表目錄-----------------------------------------------------------viii
圖目錄-------------------------------------------------------------ix
第一章 緒論--------------------------------------------------------1
第一節 研究背景與動機--------------------------------------------1
第二節 研究目的--------------------------------------------------3
第三節 名詞解釋--------------------------------------------------3
第二章 文獻探討----------------------------------------------------4
第一節 病歷的定義與結構------------------------------------------4
第二節 醫師特質--------------------------------------------------6
第三章 研究方法---------------------------------------------------13
第一節  研究假設與研究架構---------------------------------------13
第二節 資料來源與研究對象---------------------------------------14
第三節 研究限制-------------------------------------------------14
第四節 研究變項操作型定義---------------------------------------15
第五節 資料分析方法---------------------------------------------16
第四章 研究結果---------------------------------------------------17
第一節 研究樣本之基本資料---------------------------------------17
第二節 醫師科別與病歷完成率之相關性分析-------------------------22
第三節 醫師服務量與病歷完成率之相關性分析-----------------------26
第四節 醫師性別與病歷完成率之相關性分析-------------------------28

第五章 結論與建議-------------------------------------------------31
參考文獻-----------------------------------------------------------33
附錄一、102年醫院評鑑項次摘要表(1.5.3)-----------------------------35
附錄二、102年醫院評鑑項次摘要表(1.5.9)-----------------------------36
附錄三、102年醫院評鑑項次摘要表(2.9.4)-----------------------------37
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