運用資訊系統降低血液透析記錄不完整率

正確完整的照護紀錄，有利於醫護溝通、維持病患照護品質。本院血液透析中心手寫透析紀錄常有遺漏問題，經專案小組進行透析紀錄查檢，發現紀錄不完整率為19.5%，經由訪談、歸納，確立主要原因為：透析照護和紀錄時間重疊，導致護理人員來不及寫；透析中護理人員未隨手記錄，事後又忘記補記錄；表單未整合，無固定評估時間；透析紀錄表格細小，容易遺漏；依個人判斷書寫處置紀錄。藉由簡化血液透析紀錄、制定紀錄書寫規範、建置血液透析紀錄資訊系統、舉辦教育訓練、制定查核及實施獎勵辦法。實行改善措施後，血液透析紀錄不完整率由19.5%降至3.8%。本專案的實施，確實改善單位護理同仁血液透析紀錄完整率低之問題，提升病人安全及照護品質。

關鍵字

血液透析；護理紀錄；資訊系統

並列摘要

Complete nursing records enable effective communication between medical personnel and can improve the maintenance of patient care quality. Our Hemodialysis Center, which prepared hemodialysis records by hand, regularly experienced incomplete records. Therefore, a project team conducted a hemodialysis record survey and found that 19.5% of hemodialysis records were incomplete. We subsequently conducted interviews and generalized the results, from which the causes of incompletion were identified: (a) the time for providing and recording the hemodialysis care overlapped each other, which renders the nursing personnel to have insufficient time to record properly; (b) nursing personnel did not make records immediately after the hemodialysis treatments and often forgot to complete them; (c) there were multiple types of forms that were not integrated and evaluated for effectiveness; (d) the hemodialysis record forms were small and easily missed; and (e) the nursing personnel were not provided with a standard for recording their observations during the process. To alleviate these problems, the process of recording hemodialysis observations were simplified, record-writing standards were formulated and implemented, a hemodialysis record information system was created, programs for continuing education on hemodialysis observational recordings were hosted, evaluation times of the information system were scheduled, and incentives for using t he information system were implemented. After the aforementioned measures were followed, the percentage of incomplete hemodialysis records decreased from 19.5% to 3.8%. By implementing the project, we improved the incompletion rate of hemodialysis records and elevated patient safety as well as the care quality of hemodialysis patients.

並列關鍵字

hemodialysis ； nursing records ； information systems

參考文獻

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黃惠玲、張元玫、歐李美智、湯慎元、李亭亭（2011）．資訊科技在護理應用-應用決策支援系統於門診護理指導資訊系統．護理雜誌，58(1)，79-84。doi:10.6224/JN.58.1.79

鄧慶華、鄭雅中、陳素根、李宜靜、張勝立、陳穎從、柴怡茜（2014）．智慧化健康照護創新系統之應用和綜合效能．醫務管理期刊， 15(2)，128-149。doi:10.6174/JHM2014.15(2).128

謝淑玲、黃小倩、高芷華（2015）．血液透析治療前、中、後之操作技術．腎臟與透析，27(2)，53-56。doi:10.6340/KD.2015.27 (2).01

Marinis, M. G., Piredda, M., Pascarella, M, C., Vincenzi, B., Spiga, E, Tartaglini, D., Matarese, M. (2010). If it is not recorded, it has not been done!'? Consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing, 29(11-12), 1544-1552. Doi: 10.1111/j.1365-2702.2009.03012.x

國際替代計量

運用資訊系統降低血液透析記錄不完整率

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