提升準專科護理師身體評估完整性之專案

「身體評估」是醫療業務常規執行相當重要的技能，正確有效率的評估，可以提升醫療判斷及減少病人處於危機狀態。本專案藉由實際稽核準專科護理師身體評估，發現完整性僅43分。經現況分析確立問題為身體評估工具缺乏一致性、缺乏教育訓練、缺乏標準流程與稽核機制、臨床教師授課標準不一致。訂定改善措施，如：統一身體評估工具、舉辦在職教育、制訂規範與稽核制度、舉辦臨床教師共識會。經由專案實施後，準專科護理師身體評估完整性由43分提升至75分，達專案目的。專案實施後有效提升準專科護理師的評估能力，及早發現病人之問題，並提升整體醫療照護品質，建議未來學校將此技術納入教學評估必修課程，以增加學生對於評估流程的概念及完整性。

關鍵字

身體評估；準專科護理師；醫療品質

並列摘要

Physical assessment is the crucial skill for routine execution of medical practices. Accurate and efficient assessments improve medical judgment and also reduce the risk of patient in crisis. This project is based on the physical evaluation of quasi nurse practitioners, and the result showed integrity scores merely around 43 points. After analyzing the current situation, we found the causes include: the inconsistency of physical measuring tool; lack of educational and training; absence of SOP and auditing mechanisms; inconsistent teaching standards in lectures of preceptors. The established solutions were: unifying the physical measuring tool; organize on-job trainings education; develop SOP and auditing mechanisms; organize clinical teacher consensus meeting for preceptors. The integrity scores of physical assessments from those quasi nurse practitioners elevated from 43 points to 75 points after this project implementation, and the objective of this project was achieved. After the implementation of the project, it effectively improve the assessment ability of quasi nurse practitioners, detection of patient problems took place earlier, and enhanced the overall quality of medical care. Physical assessment process is highly recommended to be incorporated as a compulsory curriculum to improve students' understanding of concept and completeness of the assessment process.

並列關鍵字

physical assessment ； would-be nurse practitioner ； quality of medical care

參考文獻

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提升準專科護理師身體評估完整性之專案

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