提昇護理紀錄書寫完整性之改善方案

The Project of Promoting Nursing Records Completeness

常玉琴(Yuh-Chirn Chrang) ； 黃惠姿(Huei-Tzu Huang) ； 王襄華(Hsiang-Hua Wang) ； 張雅惠(Ya-Huei Chang) ； 樊君儀(Chun-I Fan) ； 高麗娟(Li-Chuan Kao) ； 戴千淑(Chien-Shu Tai)

《榮總護理》 26卷3期 (2009/09) Pp. 304-310

https://doi.org/10.6142/VGHN.26.3.304

摘要

完整的護理紀錄是病人安全及照護品質的基本要素。本專案目的為提昇護理紀錄書寫完整性。某醫學中心督導長單位中層品管組查核護理紀錄書寫完整率僅有68.2%，未達閾值，經現況分析後確立原因為：未及時書寫、筆誤、對護理紀錄書寫方式認知不一致、未及時掌握相關規定、制式化書寫致欠缺個別性等因素。針對以上原因提出解決對策有：製作護理紀錄查檢表、貼提醒標語、留言提醒更改、加強宣導、制定參考範例、成立諮詢人才庫、建立訊息傳遞網、舉辦在職教育、每週稽核、配合個別輔導及情境討論等方法。實施四個月後護理紀錄書寫完整率已提高至82.7%，目標達成率122.9%，進步率21.3%，本專案為督導長單位跨科及跨組別共同攜手合作，有效提昇護理紀錄完整性。

關鍵字

護理紀錄 ； 護理專案 ； 書寫完整性

並列摘要

Good quality records are essential to safe and effective patient care. The objective of this project was to improve nursing record completeness. Our statistical result showed only 68.2% lower than the threshold of nursing records were complete. The problems were: not documenting immediately, a lapse of the pen, lack of and not catching on standardizing methods and individuality. Discussed solutions were: setting up checklists, reminders, standardized forms, inquiry center, message relay networks, enhancing instructions, weekly audit and holding lectures.
After implementation, the completeness was increased to 82.7%. The goal achieved rate was 122.9% with improvement rate being 21.3%. This project was collaborated with assistance and showed effective improvement to nursing record completeness

並列關鍵字

nursing records ； nursing project ； records completeness