「問題導向型」住院病歷結構 與書寫注意事項

蔣維凡

2014/09/18

何謂病歷

• 患者疾病的發生、發展、結果，進行檢查、診斷、治療等所有醫療人員醫療活動過程的記錄。

病歷

研究 教學

經濟 保險給付

法律文件

溝通

病歷詳實記錄之重要性

• 醫學研究層面 – 通過臨床病歷總結分析，尋求疾病發生、發展、治療轉歸的客觀規律

• 法律層面 – 處理醫療事故、醫療糾紛的法律依據

• 教育層面 – 汲取經驗、教訓，改進工作，提高醫療質量

• 溝通工具 – 醫護成員共同照護

• 社會層面 – 保險給付依據

何謂電子病歷

• Computer-based Patient Record (CPR)

– 病歷電子化

• Electronic Medical Record (EMR)

– 電子病歷

• Electronic Health Record (EHR)

– 電子健康照護紀錄

– 電子健康檔案

Problem Solving 問題解決

• 線性思考

History

review

Physical

exam.

Image &

lab study Problem

Tentative Diagnosis

Problem Solving 問題解決

• 跳躍式思考

Problem

History review

Image & Lab

study

Tentative Diagnosis

Physical exam.

住院病歷書寫

Problem Oriented Medical Record

• 以病人問題為方向，將之系統性分析解決

SOAP DAP PAP

Subjective Data Problems

Objective

Assessment

(status)

Assessment

(status)

Assessment

(status)

Plan Plan Plan

了解主角(病人)

• 每一個相同問題對於不同主角有不同意義

• 社會背景掌握

– 基本資料：社經地位、家庭情形、教育背景。

– 需求要的是：可用、好用、耐用、好看?

• 醫療背景

– 有何先天疾病。

– 曾經和現在有何疾病?治療情形?

– 治療風險掌握。

Admission Note架構

• Biographic data

• Chief complain & History(duration)

• Medical history

• Social & Family history

• Review of systems

• Physical examinations

• Lab & Radiographic examinations

• Impressions/Diagnosis

• Treatment plannings

Patient Biography

• 探討病因需要所需資料

– 年齡/性別/婚姻

– 職業(Occuptation)：職業相關疾病

– 住處(Residency)：流行病與環境衛生、出院照護可近性與追蹤可能性

– 族群(Ethnic origin)：相關遺傳性疾病、語言、文化相關

– 過去病史：與主訴相關性或連貫性

– 過敏史(Allergy)：用藥安全、主訴相關性

Chief Complaints

• 以病人口語方式，將最憂慮及困擾之症狀(symptoms)並配合時間做簡短敘述。

• 避免將診斷或相關字眼在此提出。

• 範例 – Left upper-side toothache for 3 days. I was

referred from Dental Clinic

– Food impaction at right posterior teeth for 2~3 months

– A swollen mass at right cheek for one month

– Dental cavity and toothache for one month

Present Illness架構

• 開場白

– 基本資料中之關鍵字+過去病史+主訴

•必填關鍵字=age, gender, occupation

•選擇性關鍵字=marital, ethnic, residency

• 第二段

– 故事性方式介紹

– 有系統性介紹

– 提供反證，以證明推論正確。

範例 Oral Cancer 開場白

• This 60-year-old married man, a truck driver, with diabetes and hypertension was admitted via clinic because a growing mass over right cheek for 3 months.

• Problems (keywords)

– Hypertension, Diabetes, Cheek mass

範例 Oral Cancer 繼承段

• This patient had risk oral habits for over 20 years and limited mouth opening since 10 years ago. Review his dental history, he missed some of his teeth in the pasting 5 years and did not has a regular dental treatment. He had been diagnosed to have hypertension and diabetes 3 years ago. He did not regular visit physician except he felt dizziness and bone ache.

Admission Note- Present Illness

• This is a 65-year-old man with a history of hypertension for 10 years, diabetes for 7 years, gout for 5 years, with regular medications.

• He suffered from an ulcer over left buccal mucosa for more than 3 months. He did not ask for medical help because the symptom did not annoy him much.

Admission Note- Present Illness

• There was no orthopnea, palpitation, chest pain, cough, or cold sweating. The dyspnea usually experienced when she walked faster or go up the stairs. Recently dyspnea was noted after 50-meter walk.

Admission Note- Medical History

• 疾病、手術、住院史

• 用藥史

Admission Note- Social/Family Hx

• 個人旅遊史:感染症高風險國家

• 生活史：菸、酒、檳榔、其他高風險飲食

– 使用量、用多久，如1 ppd for 20 yrs

• 家族史：遺傳性疾病，以三代為範圍之pedigree tree 劃出最佳

Admission Note- ROS/PE

• History taking (review of system)、physical examination等都要很確實著重要點。

– ROS是指以前問題，不管現在為inactive/active problem與否，應予以紀錄。重點是將主訴以外潛藏的active problems發掘出來。

– Physical examination則是指現在身體狀況，僅寫出active signs。

– 藉此兩大項目利於病情及其相關因子有正確的掌握，選擇適當的檢驗項目。

Admission Note- Lab/Image

• 檢驗檢查結果若是住院前完成，但是與本疾病歷程相關，應於Admission note註明

• 主要診斷應說明與本主訴相關之疾病名稱

– 鑑別診斷應註明於主要診斷之後

– Verrucous tumor, DDx squamous cell carcinoma

– 其他口腔active problems關聯的診斷，應置入次要診斷(項目第2、第3….)

• 相關診斷一般為active的系統性疾病

– Diabetes, Hypertension

Admission Note- Plannings

• 診療計畫依入院順序進行之diagnostic workup, definite treatment, instructions for patient依次寫出 – Image workup: neck CT, abdominal echo, bone

scan, panorex, CXR

– Combined surgery with Chest Surgeon Dr.Lu & Plastic Surgeon Dr.Chou

– Intensive care at ICU for 3~5 days

– Wound/Oral care and instruction

– Adjuvant therapy depending on Pathology

診療計畫書

診療計畫書- 中文繕打

• 應註明(疑似)疾病名稱

• 相關重要/重大檢查項目

• 手術方法

• 術後衛教、復健、營養指導

• 相關輔助治療如化學治療、放射治療

• 病患簽名、主治醫師簽名、解釋繕打醫師署名

柳營奇美醫院 住院病歷常見問題

Sample 1

盡量減少縮寫，依柳營奇美縮寫規範書寫

無異常發現應以症狀項目分

列

Sample 2 Major 主訴 Minor 主訴

Sample 2 Major 診斷放前面 Minor 診斷放後面

Sample 3 主訴太過原始，可放在PI。應以此次治療主訴為主

身體檢查每一系統應有3~5項目

Sample 3

Sample 4

Sample 4

日常病歷紀錄

Progress Note

• problem-oriented medical record (POMR)方式記載

– 最後須有分析(Assessment)與狀態評估

– 處理之道(plan to do/treatment planning)

– 基本上可以簡化成Problem-Assessment-Plan to do (PAP) or S-O-A-P

• 一個問題進行一次S-O-A-P循環

– 所以…..三個問題就三個P-A-P or S-O-A-P

POMR組成之病歷架構

Database

1. Patient profiles

2. History

3. Physical examine

4. Laboratory data

5. Image workup

Problem list

#1 Oral cancer

#2 Hypertension

#3 GI disturbance

Treatment planning

Diagnostic workup

Therapeutic plan

Patient education

#1 oral cancer, post-op day 10

S: Surgical wound pain

O: Erythema(-), local heat(-), swelling: mild

A: Scar contraction, stationary status

P: Rehabilitation and analgesics

Problems List

Problems Initiation

Date

Active

/Inactive

Date of

inactive

1 Hypertension 2000 A

2 CAD, stable

angina 2005 A

3 UTI Feb 25, 2012 I

4 Facial cellulitis Mar 1, 2012 A Mar 1, 2012

PMOR紀錄範例

• Problem 1 S: nil O: BP=150/95 mmHg A: Hypertension, not controlled P: Keep present medications Advise the patient restricting salt taking

• Problem 4 S: Pain over left face O: Swelling and erythema subside A: Facial cellulitis, improved P: Keep the present antibiotic up to one week. Mouth

opening exercise

Weekly Summary

• 可仿照problems list方式作summary，然後在逐一針對各個問題進行SOAP

• 治療計畫可以依各個問題進行發揮，或是整體性於最後進行論述。

• 為出院病歷住院治療經過作準備

SBAR

• 『SBAR』是一種用於交班的溝通方式，源於核子潛艇中彼此的溝通，後被Kaiser Permanente 醫院改編成適用於健康照護，以改善溝通的方法。其為Situation（狀況）、Background（背景）、Assessment（評估）、Recommendation（建議）之縮寫。

• 可運用於值班之交班、病人轉換單位之交接、特別護士（看護）之交接班、病人院內運送或轉院之摘要、異常事件報告、案例討論之紀錄、電話之諮詢等。

SBAR

• Situation (Active Problems) (Inactive Problems)

– What is happening at the present time?

• Background (Present Illness)(Pathology)(Surgery)

– What are the circumstances leading up to this situation?

• Assessment (Preliminary Diagnosis)

– What do I think the problems are?

• Recommendation (Treatment planning and Medication)合

併團隊照護紀錄

– What should we do to correct the problems?

團隊會議紀錄

• 泛指可將相關醫療團隊間建議與診斷置入 – 會診病歷內容。

– 復健治療計畫、營養評估與處置。

– 放射治療評估、化學治療評估等等。

• 須於該處委請照護之醫護團隊(該月柳營之住院醫師、主護)簽名。

• 格式範例 – Diabetes Endocrinologist diet control,

insulin 12u tid

重要檢驗檢查開立理由與結果

• 開立重要檢驗/檢查(eg CT, MR, 特殊抽血)，應於當日progress note的”P”書寫理由

• 結果出來應及時於當日書寫於progress note中的”O”之中，並於 ”P”中紀錄預計處理之道

Discharge Summary

• 基本上比照Weekly summary

• 重點是出院相關準備及計畫

– 復健計畫

– 口腔照護計畫

– 輔助治療: 放射治療化學治療計畫

– 營養照護計畫

– 心理輔導計畫

手術相關病歷紀錄

Pre-operative Note

• 提供術前準備工作整理及自我提醒之工具

• 亦同於一般progress note 之on duty note

Post-op Note

• 須註明相關手術前後診斷與重大發現

• 目前疾患之狀況，如引流管、敷料傷口種類

– Active or Inactive

• 術中I/O, blood loss

• 術後外觀(general appearance )、意識(mental state)、生命現象(vital signs)、四肢血流灌注(peripheral perfusion)及和氧狀態(oxygenation status)

• 建議治療計畫與重要注意事項

其他病歷紀錄

Transfer/Acceptance Note

• 須註明相關診斷與目前狀況active or inactive

• 重大處置及日期

• Vital signs, I/O, Consciousness change

• 建議診療方向與轉診目的

• 團隊成員簽名

常見錯誤用法 1/3

• Cancer was told – The patient was informed to have cancer

• Conscious clear – Consciousness : clear

• The patient went to LMD/LDC, but in vain – The patient went to LMD/LDC for help, but the

symptom did not improve

• Cancer impresed – Cancer was suspected

– The patient was suspected to have a cancer

常見錯誤用法 2/3

• The patient developed abdominal pain and high fever – Abdominal pain and high fever developed since 3

days ago

• Thanks for your consultation – Thanks for your referral or your consultation

request

• Nothing particular (NP) – Unremarkable

常見錯誤用法 3/3

• MBD (may be discharged) order

– Discharge order, Discharge note

• AAD (against advise discharge)

– Discharge against medical advise

• According to the statement of patient inappropriate

– According to the patient