運用跨團隊合作提升專科護理師住院病歷書寫之完整性

A Cross Team Collaboration Project for Improving the Integrity of Nurse Practitioner Writing Medical Records

鄭沛綾(Pei -Ling Cheng) ； 林莠美(Yu-Mei Lin) ； 李千佩(Chian-Pei Li) ； 陳芝文(Chih -Wen Chen)

《領導護理》 21卷4期 (2020/12) Pp. 103-117

https://doi.org/10.29494/LN.202012_21(4).0008

摘要

病歷提供醫療服務者訊息傳達與溝通的工具，團隊可透過病歷短時間內即能知悉病情並提供醫療照護，完整的病歷可呈現醫療成效。臨床上發現專師花費許多時間在病歷書寫，內容過於簡化且常有遺漏，經現況分析確立原因為病歷書寫標準規範簡略、缺乏可參考的病歷書寫範本及教案、缺乏醫護英文課程、電腦介面不友善費時、缺乏獎懲制度。經由修定病歷書寫標準規範，依專科性制定病歷書寫範本及教案、舉辦醫護英文課程、推行住院病歷書寫電子化、病歷書寫介面改版、於電腦資訊系統建立病歷書寫常用片語及範本、建立獎懲制度後，病歷書寫完整性由56%提升至85%達改善目的，藉由清楚且詳實的病歷記載，了解病人的治療計劃，更可作為學習、研究及教學之參考。

關鍵字

跨團隊合作 ； 專科護理師 ； 住院病歷書寫

並列摘要

The medical record provides a tool for information transmission and communication of the medical service providers. The team gets to know the condition and provide medical care through the medical record in a short period of time, and the complete medical record can show the effectiveness of the medical treatment. Clinically, it is found that the specialists spend too much time writing the medical records. The content is too simplified and often falls short. The analysis of the current situation has established that the standard of medical records is plain; the medical records and teaching plans lacking references; insufficient medical English courses; and the computer interface are not friendly; time-consuming, and inadequate reward and punishment system. Through the revision of medical record writing standards and specifications, the preparation of medical record writing templates and teaching plans are developed according to the specialty area; the establishment of medical English courses, the implementation of electronic writing for medical records in hospitals, the revision of medical records templates interfaces in computer information systems, and the establishment of rewards and punishments. After the system implementation, the integrity of the medical record has improved from 56% to 85%. The clear and detailed medical records can be used to understand the patient's treatment plan, and also serves as a reference for learning, research and teaching.

並列關鍵字

cross team collaboration ； nurse practitioner ； medical records

參考文獻

王曼蒂、楊淑慧、宋佳穎、劉淑芳、陳碧蓮（2010）．影響護理人員使用護理紀錄標準化範本之相關因素．榮總護理，28（3），241-248。doi:10.6142/VGHN.28.3.241

林小娟、周子昌、許淳森、李隆熙、邱濬昇、張毓仁（2010）．JCI評鑑與病歷紀錄品質．病歷資訊管理，10（1），1-11。doi:10.29741/JMHIM.201012.0001

林惠娥、李建德、曾昱龍、林新景、李逢君、陳明志、林威宇、黃秋慧、劉家壽（2013）．提升住院醫師病歷紀錄品質教學活動之探討．醫務管理期刊，14（3），244-267。doi:10.6174/JHM2013.14(3).244

周登偉、賴芳足、李秋慧、徐華吟、葉淑 如 、 呂錦 慧 、 林佩 勳（2013）．導入團隊資源管理對加護單位病人安全文化之影響．醫院，46(4)，32-41。doi:10.30018/JECCM.201106.0010

范姜玉珍、楊慧貞（2012）．共創同心圓探討護理同仁與醫療團隊的合作．志為護理─慈濟護理雜誌，11(2)，16-19。doi:10.6974/ TCNJ.201204.0016