Cheng Kavia, Hart Jade
Patient Information Management Services, Women's and Children's Health Service, Perth, Western Australia.
Health Inf Manag. 2004;33(4):127-33. doi: 10.1177/183335830403300405.
Following the Douglas Inquiry into medical practices and processes, a number of reforms were made to the medical records structure at the King Edward Memorial Hospital for Women (KEMH) in Perth, Western Australia. An audit was undertaken to investigate staff compliance with the new medical record structure, and to identify significant issues arising from the new filing sequence and dividers. The medical record components (correspondence, emergency, outpatient, inpatient and diagnostics) were analysed through random selection of records with recent inpatient and/or outpatient episodes. Interviews with both clinical and clerical staff at KEMH were also conducted to gather general feedback. The main issues identified in the study were a lack of understanding of the operational instructions by staff, incorrect filing procedure, and allocation of inappropriate dividers. The following recommendations were developed to address these issues: revision of all medical record forms (in particular unauthorised medical record forms); education of both clinical and clerical staff; expansion of the operational instructions into a comprehensive guide for staff; development of a new process for signing any results or reports; and compilation of a sample medical record as a reference for staff.
在对医疗实践和流程进行道格拉斯调查之后，西澳大利亚州珀斯的爱德华国王纪念医院（KEMH）对病历结构进行了多项改革。开展了一项审计，以调查工作人员对新病历结构的遵守情况，并确定新的归档顺序和分隔物引发的重大问题。通过随机选择近期有住院和/或门诊记录的病历，对病历组成部分（信件、急诊、门诊、住院和诊断）进行了分析。还对KEMH的临床和文书工作人员进行了访谈，以收集总体反馈。该研究中确定的主要问题包括工作人员对操作说明缺乏理解、归档程序不正确以及分隔物分配不当。针对这些问题提出了以下建议：修订所有病历表格（特别是未经授权的病历表格）；对临床和文书工作人员进行培训；将操作说明扩展为工作人员的综合指南；制定签署任何结果或报告的新流程；以及编制一份示例病历作为工作人员的参考。
