比較護理診斷為主的問題導向記錄法與焦點護理紀錄法之成效差異

Comparison of Outcome Between Nursing Diagnosis of Problem Oriented Recording Method and Focus Charting Method.

黃芳子(Fan-Tz Huang)

指導教授 ： 張文英

臺北醫學大學/護理學院/護理學研究所/碩士(2003年)

摘要

本研究屬於一描述性病歷回顧研究。主要目的在探討及比較護理診斷為主的問題導向護理記錄法(S.O.A.P.I.E.)與焦點護理記錄法(D.A.R.T.)之成效差異。本研究採橫斷面調查(cross-sectional)，樣本取於民國八十七年台北地區，醫院評鑑為區域醫院的一所醫院之護理人員，此所醫院分別於過去推行過護理診斷為主的問題導向護理記錄法或焦點護理記錄法，而現在以其中一種為護理記錄法者。資料的收集工具為參考文獻自擬護理記錄完整性評量表及護理人員對護理記錄滿意度量表，分別針對符合入選條件之出院完成病歷以回溯病歷方式及護理人員問卷填寫方式完成資料的收集。本研究正式資料收集日期於91年3月至91年4月下旬完成，共發出40份問卷，回收40份，回收率100﹪，其中有效問卷為40份，回收問卷有效率100﹪；病歷回溯分為護理診斷為主的問題導向護理記錄法及焦點護理記錄法病歷，每位受測護理人員5本，共各為200本。資料以平均數、百分比、標準差、單因子變異分析等統計方法進行處理和分析。 研究結果發現：1. 以護理診斷為主的問題導向護理記錄法臨床記錄的完整性平均得分為3.26分(滿分為6分)，焦點護理記錄法臨床記錄的完整性平均得分為3.31分(滿分為6分) 2.以護理診斷為主的問題導向記錄法臨床運用滿意度，平均得分為2.71分(屬滿意)，焦點護理記錄法臨床運用滿意度，平均得分為2.91分(屬滿意) 3.二者記錄法於臨床運用滿意度成效成效有顯著差異(p=0.011)；但在護理記錄完整性上，二者記錄法無顯著差異(p>0.05) 4.每日上班於臨床護理工作中在護理記錄所耗費時間上，以護理診斷為主的問題導向護理記錄法，平均為88.5分，焦點護理記錄法護理記錄法，平均為73分；在自行選擇以何者方法作為臨床護理記錄法時，有80﹪護理人員選擇以焦點護理記錄法，只有20﹪護理人員選擇以護理診斷為主的問題導向護理記錄法 4.基本屬性項目對護理診斷為主的問題導向護理記錄法與焦點護理記錄法於臨床運用成效並無影響；但基本屬性中以病房工作年資、職稱、年齡對護理紀錄法滿意度細項內容有影響，但醫院服務年資、學歷、科別對護理紀錄法滿意度細項內容無影響，而醫院服務年資、病房工作年資、科別對護理紀錄法書寫之完整性細項內容有影響，但年齡、職稱、學歷對護理紀錄書寫之完整性細項內容無影響。 最後，本研究結果將有助於臨床護理主管選擇護理記錄法之參考，並可做為簡化護理記錄工作之參據。

關鍵字

護理診斷 ； 焦點護理記錄法

並列摘要

This study was a descriptive. The primary objective was to analyze and to compare the differences in outcomes between nursing diagnosis of problem oriented recording method (SOAPIE) and focus charting method (DART). The design was cross-sectional. Samples were nurses and from a district hospital in Taipei area. Nurses who work in this hospital had experiences in using both SOAPIE and DART recoding methods before. Instruments for data collection included a self-developed nursing record assessment tool and satisfaction questionnaire. The data collection period was from March to April of 2002. The response rate was 100%. Five charts were selected for each nurse and total 200 charts were reviewed for either SOAPIE or DART recording methods. Data were then analyzed by mean, percentage, standard deviation, and one-way ANOVA. The results were as follows. 1. The level of completeness for SOAPIE was 3.26 (total score was 6), but DART was 3.31. 2. The average satisfaction score was 2.71 (means satisfaction) for SOAPIE, but 2.91(means satisfaction) for DART. 3. A significant difference was found in satisfaction scores between SOAPIE and DART (p =0.011). But, no significant difference was found for the level of completeness between these two recoding methods (p >0.05). 4. The average nurse's time spending on nursing record was 88.5 minutes for SOAPIE and 73 minutes for DART every day. For asking about what method would choice in the future, about 80% of nurses selected , DART only 20% selected SOAPIE. 5. Satisfaction was affected by years of unit working experience, credential, and age, but other demographics did not. The level of completeness were affected by hospital working experience, unit working experience, and credentials. To sum up, the findings of this study can be used to assist clinical nursing managers to select nursing recording methods and to simplify the contents of nursing recording methods.

並列關鍵字

Nursing diagnosis ； Focus charting

參考文獻

楊勤熒、盧美秀(1998).人性關懷教育訓練對護理人員人性關懷 知識、態度、行為影響的探討.護理研究，6(3)，206-218。

伍麗珠、劉長安(2000).探討白斑護理人員之工作內容及時數分配.榮總護理，17(1)，63-71。

盧孳豔(1998).國際護理作業分類系統(ICNP)之現況與展望. 護理雜誌，45(2)，35-39。

蔣立琦(1998).國內護理診斷的發展現況與未來展望.護理雜誌 ，45(2)，28-34。

鄭綺、盧美秀(1997).建構護理診斷和護理實務間的橋樑，護理 雜誌，44(6)，53-57。