提升透析電子護理記錄完整性之專案

Project for Promoting the Completeness of Electronic Dialysis Nursing Records

林育如(Yu-Ju LIN) ； 林雯萱(Wen-Hsuan LIN) ； 王敏芳(Ming-Fang WANG) ； 葉淑敏(Shu-Min YEH) ； 徐紫娟(Tzu-Chuan HSU) ； 張玉婷(Yu-Ting CHANG)

《護理雜誌》 66卷1期 (2019/02) Pp. 93-100

https://doi.org/10.6224/JN.201902_66(1).11

摘要

背景：完整的透析電子護理記錄是呈現護理照護過程與品質重要的依據，更是醫療團隊間重要的溝通橋樑。經現況分析，發現護理人員對透析電子護理記錄系統操作介面不熟悉、缺乏系統操作教育訓練、透析電子護理記錄系統設計不佳、缺乏透析電子護理記錄書寫指引，及缺乏透析電子護理記錄書寫稽核制度，導致透析電子護理記錄書寫之完整性僅58.2%。目的：提升透析電子護理記錄完整性大於90%。解決方案：修改透析電子護理記錄系統、建置透析電子護理記錄片語範例、製作透析電子護理記錄操作手冊、進行系統操作在職教育、執行記錄書寫臨床情境模擬演練與透析資訊護理師制度，及落實透析電子護理記錄稽核制度。結果：透析電子護理記錄完整性提升為96.0%；護理師書寫記錄時間由平均21分35秒縮短至8分15秒。結論：良好的資訊系統確實有效提升透析電子護理記錄完整性，也縮短記錄時間，有助於確保透析病人之照護品質。

關鍵字

電子護理記錄 ； 血液透析 ； 護理專案

並列摘要

Background & Problems: Obtaining complete electronic dialysis nursing records, a tool that facilitates communication between medical teams, is critical in terms of maintaining the continuity of nursing procedures and nursing quality. An analysis of our unit indicated that nurses lacked sufficient familiarity with electronic dialysis nursing record systems. Moreover, they received insufficient training in operating these systems and lacked the guidelines necessary to maintain these records properly. Furthermore, these systems tend to be poorly designed, and an inspection system for dialysis nursing records is currently unavailable. These factors led to a rate of record completeness of only 58.2%. Purpose: To raise the rate of completeness for electronic nursing records to above 90%. Resolution: An intervention was conducted to accomplish seven tasks. These tasks included: modify the electronic dialysis nursing record system, input preset phrases in order to facilitate record compilation in the system, devise a manual to instruct staff on recordkeeping procedures, organize in-service training on system operations, conduct clinical scenario simulations for nurses to practice operating the system, recruit informatics nurses to teach other nurses about the operations, and implement an inspection system for these electronic records. Result: After implementing the intervention, the rate of completeness for electronic nursing records improved to 96% and the average time required for nurses to complete a nursing record decreased from 21 mins 35 s to 8 mins 15 s. Conclusion: The developed intervention significantly improved the completeness of electronic nursing records, reduced the time required for recordkeeping, and ensured adequate nursing quality for dialysis patients.

並列關鍵字

electronic nursing records ； hemodialysis ； nursing project

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