臺灣博碩士論文加值系統

電子病歷中包含手術報告，手術報告中所記載的臨床訊息主要為臨床醫學教學和醫療法律與醫學研究的重要依據來源，對於促進臨床醫療研究與手術後病患醫療照護服務的品質提升擁有極高的醫學參考價值。
在電子手術記錄的文件格式結構上，主要採用自由文字描述為主，廣泛地使用敘事文方式來進行手術記錄在臨床資料輸入上非常耗時，並且會產生紀錄描述不夠具體以及臨床訊息遺漏的情況發生，此外經由敘事文的方式產生的手術報告需進行人工閱讀才得以瞭解手術記錄內容，無法即時擷取臨床數據、資料整合、統計分析、病患病況的診斷與醫學知識獲得。
為增進醫師進行手術記錄輸入的效率與提昇資料的完整性，本研究試圖建立結構化手術記錄系統提供整形外科醫師進行手術記錄，藉由結構化手術臨床表單所產生的結構化臨床資料，有效提供數據分析、資料辨識互通與未來在臨床研究檢索與建置醫學決策輔助資訊系統應用的可能性，並提升手術記錄臨床訊息在手術醫療品質與臨床研究醫學的應用價值。

Operative report is part of the Electronic medical record, which can provide the clinical information, to bring a high reference value for clinical research, medical law and improve the quality of clinical care.
The traditional clinical record of electronic operative reports recorded data by the free-text description and narrative methods, which is makes difficult to identification and increase the reducing readability for operative report. In order to enhance the physician efficiency for clinical recording, medical data integration and analysis clinical information, this study attempted to create a structured electronic operative reporting system to improve the possibility of operative report retrieval applications and medical research.

中文摘要 II
Abstract III
目錄 IV
圖目錄 V
表目錄 VI
第一章 緒論 1
第一節 研究背景 1
第二節 研究動機 3
第三節 研究目的 4
第二章 文獻探討 7
第一節 聽打手術報告記錄 7
第二節 文字樣板手術報告記錄 7
第三節 結構化手術報告記錄 9
第四節 目前手術紀錄系統的困境 9
第三章　系統設計與研究方法 11
第一節 系統分析與設計 11
第二節 系統開發環境與功能架構 12
第三節 系統評估方法 16
第四章　系統實作與結果 18
第一節 系統功能與概觀 18
第二節 系統評測與結果 22
第五章　討論與結論 29
第一節 討論 29
第二節 研究限制 30
第三節 結論 31
第四節 未來研究方向 32
參考資料 33
附錄 36
附錄一、原始程式碼 36


圖目錄
圖2-1手術記錄系統樹狀設計 8
圖3-1雛型系統開發流程圖 13
圖3-2結構化手術記錄建置流程圖 14
圖3-3系統環境架構 15
圖3-4結構化手術報告系統功能設計流程圖 15
圖4-1病人手術清單 19
圖4-2結構化手術記錄功能畫面 19
圖4 3結構化手術記錄臨床選項功能畫面 20
圖4-4結構化手術記錄預覽編輯功能畫面 21
圖4-5手術記錄臨床資料 21
圖4-6結構化手術記錄系統易學程度 24
圖4-7結構化手術記錄系統操作的簡單程度 24
圖4-8結構化手術記錄系統的內容呈現滿意度 25
圖4-9結構化手術記錄系統的輔助記錄滿意度 25
圖4-10結構化手術記錄系統的輔助記錄滿意度 26
圖4-11結構化手術記錄系統整體滿意度 26
圖4-12結構化手術記錄系統使用意願度 27


表目錄
表3-1科技接受度問卷操作定義 16
表4-1結構化手術報告記錄系統功能表 18
表4-2系統評測問卷 22
表4-3使用者背景資料表 23
表4-4系統滿意度分析表 28

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