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1 牙醫門診病歷常見問題與解決之道蔣維凡 2012/07/07

2 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教學溝通研究經濟保險給付病歷法律文件

3 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

7 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

8 電子病歷之優點減少醫療疏失 1999 美國醫學研究機構發表論文顯示每年因醫療疏失直接與間接死亡人數高達 98,000 人經由資訊科技協助此比率可望下降 55% 資訊科技對於醫療照護品質提升具最大效益便是電子病歷發展

9 Problem Solving 問題解決線性思考 Problem History review Physical exam. Image & lab study Tentative Diagnosis

10 Problem Solving 問題解決跳躍式思考 Problem History review Image & Lab study Physical exam. Tentative Diagnosis

11 Problem Oriented Medical Record 以問題問題為方向, 將病人問題逐一分析解決 SOAP DAP PAP Subjective Objective Assessment (status) Data Assessment (status) Problems Assessment (status) Plan Plan Plan

12 了解主角 ( 病人 ) 社會背景掌握基本資料 ( 社經背景家庭情形 ) 需求為何?( 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? 治療風險掌握每一個相同問題對於不同主角有不同意義不同意義

13 Basic Data 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): 流行病與衛生出院照護與追蹤族群 (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

14 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

15 Present Illness 開場白基本資料中之關鍵字 + 過去病史 + 主訴第二段必填關鍵字 =age, gender, occupation 選擇性關鍵字 =marital, ethnic, residency 故事性方式介紹有系統性介紹提供反證, 以證明推論正確

16 Oral Cancer 開場白 This 60-year-old 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

17 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 for dizziness and bone ache.

18 牙醫相關之病歷範疇門診病歷會診病歷住院病歷手術紀錄病歷

19 門診病歷書寫注意事宜

20 SAMPLE 1 最初應將 abscess of upper vestibule space 加入腫痛狀況有無改善?

21 主觀 (Subjective) 資料 Major problems and history 與主訴病史可以醫師詢問後以專業語氣書寫問題則以主訴問題為主但是可加入相關之問題 eg. Diabetes, Hypertension 主訴儘量以病人說話的方式來紀錄症狀與間隔 Swollen gum, Dental cavity, facial swelling 應加註發生時間及多久前的同樣經驗 eg: for 10 days, 5 weeks ago..

22 何謂問題?? 範疇範例臨床症狀 (symptom) 實驗室檢查發現 (lab data) 個人習慣嗜好 (risk factors) 心理狀況 (psycologic) 解剖學發現 (anatomic) Toothache Thrombocytopenia Betel-quid chewing Depression Ridge atrophy 社會習慣史 (socio-economy) Financial constraints

23 Problems List 1/2 # Date Active problems Date Inactive problems 1 101/3/5 Thermal sensitive Acute pulpitis 101/4/15 Endodontic Tx 2 101/3/10 Food impaction Dental caries 3 101/3/10 Atrophic ridge left maxilla 101/3/15 A3 Z250 Resin filling 101/4/15 GBR with FDBA and EZcure 4 101/3/15 Left TMJ pain 101/5/10 Bite plate therapy 101/3/5 34, 36 tooth endo. treated and crown 101/3/5 Diabetes under medicine control

24 Problems List 2/2 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

25 Progress Note( ) 1-1 #1. Spontaneous toothache for 3 days O: Dental cavity at 26 mesial side, cold sensitive(+), biting pain(-), mobility(0) Apical film: radiolucency at 26 mesial side involving pulp A: acute pulpitis, 26 tooth P: 2 ml lidocaine infiltration. Open chamber under rubber dam isolation. Chamber and root canal debridement. 5 ml NaOCl irrigation. IRM filling. Medication with Panadol 1# qid.

26 Progress Note( ) 1-2 #1. Acute pulpitis, 26 tooth S: I felt toothache for 2 days that can be controlled by medicine. The symptom subside at the third day after root canal therapy. A: Acute pulpitis, 26 tooth; 2nd treatment P: Root canal therapy under rubber dam isolation. Working length MB(14 mm, #30), DB(13.5mm, #30), P(15 mm, #35). 5 ml NaOCl irrigation. IRM filling. Medication with Panadol 1# qid.

27 Progress Note( ) 2-1 #2. Food impaction at left lower teeth S: Food debris was impacted between 35, 36 teeth for 2 weeks O: Dental cavity at 36 mesial side with cold sensitive, biting pain(-), mobility(0) Apical film: radiolucency at 26 mesial side with pulp invovlement A: Caries, 36 tooth P: Remove food debris. Oral care instruction. Appointment for restoration on Mar 10, 2012

28 Progress Note( ) 2-2 #2. Food impaction at left lower teeth S: Food debris was impacted between 35, 36 teeth. I was arranged for restoration. O: Dental cavity at 36 mesial side with cold sensitive, biting pain(-), mobility(0) Apical film: radiolucency at 26 mesial side with pulp invovlement A: Caries, 36 tooth P: Cavity preparation and remove soft dentin. A3 Z250 resin was filled to cavity by product instruction. Oral care instruction.

29 Progress Note( ) 3-1 #3. Missing teeth at right lower arch for 2 years S: Missing right lower teeth due to severe cavity 2 years ago O: missing 36, 37 teeth. Occlusal Clearance 10~11 mm. Cawood Class 4~5 atrophic ridge. A: Atrophic edentulous ridge, 36, 37; Class 3~4 P: image study (Panorex, Dental CT). Inform the model study.

30 Progress Note( ) 3-2 #3. Missing teeth at right lower arch for 2 years O: Dental CT showed buccal/vertical bone deficiency: 36 (3/5 mm), 37(5/5 mm). A: Atrophic edentulous ridge, 36, 37; Class 4~5 P: Treatment planning Removable denture 2-STAGE reconstruction: Block bone augmentation Implant Crown

31 SAMPLE 2 cavity 有無 pulp cavity exposure 紀錄應予以量化

32 客觀 (Objective) 資料身體檢查影像學與實驗室數據客觀數據化之身體檢查結果直接項目或重大相關項目重要實驗室檢查數據影像學檢查摘錄病理學報告項目

33 SAMPLE 3 是急性牙周病之依據為何? exacerbation stage?

34 評估 (Assessment) 與病況 (Status) Acute periodontitis of 23 tooth, exacerbation Cellulitis of left lower vestibule s/p, 3rd day, improving Oral carcinoma of left lower gingiva, evaluating stage

35 SAMPLE 4 衛教資訊

36 治療與相關計畫 (Plan) 此次治療內容 Restore 26 tooth BL surface by resin filling Local scaling for 14 tooth 預計計畫診斷計畫 Arrange image study to exclude distant metastasis 治療計畫 Arrange phase I periodontal therapy 衛教計畫 Medication safety education, Wound care instruction

37 1.S SUBJECTIVE FINDING 2.O OBJECTIV FINDING 70% 3.A ASSESSMENT (10%) 過敏史 ±3 重要過去病史 ±1 主訴記載時間時間部位等是否合宜與相關之重要資訊是否記載 ±3 與主訴相關主訴相關之 physical examination 結果 ±3 重要之檢驗結果檢驗結果是否記載 ±1 是否有錯別字 ±1 診斷是否適宜 ±3 病情及療效是否記載 ±1 4.P PLAN 20% 檢驗檢查與診斷是否符合 ±3 治療對策含藥物與手術與診斷是否符合衛教病人資訊 ±3 手術介紹 ( 用藥評估 ) ±1 5. 病歷記錄是否未修改 ditto 或與前次紀錄雷同無修正?( 扣分 ) 扣 20 分 6. 病歷未用縮寫加 5 分 ±3

38 常見主要原因 2011/09~ 2012/ /02~ 2012/05 主述資訊不完整 ( 時間原因部位 ) 28(39%) 31(52%) 應給予衛教病人資訊 22(31%) 29(48%) 應記載過去病史過敏史 20(28%) 14(23%) 檢驗檢查結果未說明, 如 PAF finding lab data 15(21%) 10(17%) 主訴相關之臨床檢查資訊不足, 如 Mobility 等級 probing depth 應紀錄確切數據 ; 齲齒面記載 16(22%) 10(17%) Treatment planning 合宜性和記載後續治療計畫 10(14%) 6(10%) 診斷及鑑別疾病合宜 7(10%) 10(17%) 病情狀況或療效應加記載 5(7%) 9(15%) 主述應口語化 6(8%) 0 處置應記載部位牙位 3(4%) 0 檢驗檢查與診斷要相符合 2(3%) 10(17%) 應給予預防性止痛藥 1(1%) 0 ( 資料來源 : 柳營奇美醫院牙醫部 )

39 奇美門診病歷常見問題 1/4 在 past medical history and review of system, 勿以單一 Nil (unremarkable) 帶過特別是主訴症狀持續多久? 有無其他院所就醫? 病情有無變化? 以上皆應在此紀錄主訴要有發生部位期間 (duration) 最困擾症狀之紀錄以病人口語敘述

40 奇美門診病歷常見問題 2/4 牙醫相關影像或是檢驗檢查結果應註明可以先將檢驗檢查項目紀錄, 後方註記 pending 以利下次追蹤記載 Pathological report: pending 宜於 plan 中加註影像與實驗室檢查之合理性 Check blood sugar and CBC because of uncontrolled diabetes history Take panorex because of expanded right lower jaw

41 奇美門診病歷常見問題 3/4 診斷應與臨床檢驗檢查結果相符合切勿牛頭不對馬嘴誤用先前檢查結果或未將先前結果刪除請以量化方式紀錄病程變化如疼痛指數腫脹範圍血糖變化當下治療方式與未來治療計畫應該分開書寫 Current treatment Next treatment

42 奇美門診病歷常見問題 4/4 衛教紀錄應紀錄在治療方法之中衛教紀錄已成為當代醫療不可或缺的一部分, 應實際操做並做成紀錄與先前病歷臨床檢查無差異化切勿全然 ditto 先前紀錄

43 Summary 門診病歷的程度端看您想達成的階段以病人為中心, 初次來診病人病歷主要問題釐清電子病歷世代之相關作業瞭解過敏史重要相關警訊以資訊電子化管控可避免醫療錯誤複診病歷針對病況記載治療療效應予以記載

44 住院病歷書寫

45 Admission Note 1/7 主訴應以病患口語敘述, 並須加註發生期間 For 10 days, since 5 weeks ago.. 不超過兩個主要症狀現病史以發生時間為序, 針對該症狀嚴重程度病症進展相關對策及治療反應等項目一一敘述可以醫病問答方式進行記載

46 現病史相關治療與最近狀況 2/7 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.

47 現病史求醫過程 3/7 This 48 years man, a heavy smoker (1 ppd for 20 yrs) and heavy betel-quid chewer (20 npd for 20 yrs). He suffered from 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.

48 現病史盡量量化量化量化 4/7 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.

49 Admission Note 5/7 相關病史個人旅遊史 : 感染症高風險國家疾病及手術史 : 可分成 active & inactive 生活史 : 菸酒檳榔其他高風險飲食家族史 : 遺傳性疾病, 以三代惟範圍之 pedigree tree 劃出最佳

50 Admission Note 6/7 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,PE 則是指現在身體狀況以利病情及其相關因子有正確的掌握選擇適當的檢驗項目系統回顧 : 在短時間內扼要了解病人某個系統是否發生過痼疾, 且與本次主訴之間是否存在著因果關係

51 Admission Note 7/7 檢驗檢查結果若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次要關聯之疑似疾病名稱相關診斷 (associated diagnosis) 為系統性疾病 Diabetes, Hypertension 診療計畫依入院順序進行之 work up, definite treatment, instructions for patient 依次寫出

52 診療計畫書應註明 ( 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簽名

53 日常病歷紀錄

54 Progress Note problem-oriented medical record (POMR) 方式記載最後須有分析 (Assessment) 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 PMOR-A-P 循環三個問題就三個 P-A-P or S-O-A-P

55 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

56 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

57 Weekly Summary 可仿照 problem 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

58 年度醫療品質及病人安全工作目標一二三四五六七八九提升用藥安全落實感染控制提升手術安全預防病人跌倒及降低傷害程度鼓勵異常事件通報提升醫療照護人員間溝通的有效性鼓勵病人及其家屬參與病人安全工作提升管路安全加強醫院火災預防與應變

59 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

60 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 problem is? Recommendation (Treatment planning and Medication) 合併團隊照護紀錄 What should we do to correct the problem?

61 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

62 Discharge Summary

63 手術相關病歷紀錄

64 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

65 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

66 其他病歷紀錄

67 Transfer 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

68 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

69 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

70 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

71 The End

牙醫部病歷書寫常見問題與解決之道

牙醫部病歷書寫常見問題與解決之道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教學溝通研究經濟保險給付病歷法律文件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