แนวทางการพัฒนาข้อมูลจำเป็น ในการบันทึกเวชระเบียน หน่วยตรวจ โรคฉุกเฉิน โรงพยาบาลศิริราช

บทคัดย่อ

Guideline to Develop Emergency Medical Record Data Need in Siriraj Hospital
Sitigarn Puangtai, M.M.*, Sangtien Youthao, Ph.D.*, Tipa Chakorn, M.D.**
*Faculty of Social Sciences and Humanities, Mahidol University (Salaya) 73170, **Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
 
Objective: This study aimed to an established guideline for emergency medical record data need in Siriraj Hospital.
Methods: The study employed Mixed method research. The auditing quality of medical record had the index of item-objective congruence (IOC) of more than 0.5 when used to evaluate 689 medical records’ of emergency patients in Siriraj hospital. The results of the questionnaire regarded the evaluation of data need assessments with IOC score of more than 0.5 and coefficient of reliability of Cronbach’s alpha of 0.93 were completed by 45 personnel. In addition, a semi-structured interview about the development of data needs a guideline for emergency patients with 8 stakeholders in the management position in the Emergency Department, was analyzed with content analysis.
Results: The results found that the quality of emergency medical records of the hospital had some incomplete data which was less than half of the Joint Commission on Accreditation of Healthcare Organization (JCAHO)¹ standards. Furthermore, the 14 key data needs were essential at a significant level for emergency patients service including the need to acknowledged important additional data such as the patient’s picture, type of the emergency medical services, the time on each process, and the patient’s current healthcare plan. However, the 14 key data needs should be completed correctly by all the related medical staffs in emergency unit as well as information system unit.
Conclusion: The complete information on key data needs should be addressed as it is critical in support and treatment process of the patients. Therefore, the Department of Emergency Medicine should continue to improve the quality of information input to data need. The collaboration between doctors, nurses, medical records staffs, and other personnel together with regular quality audits and tracking of data entry is essential.