抗癌藥物護理記錄完整性之改善方案

An Improvement Project on the Integrity of the Anti-cancer Drug Nursing Records

林怡欣(Yi-Hsin Lin) ； 張玉珠(Yu-Chu Chang) ； 蔡淑芬(Shu-Fen Tsai)

《新臺北護理期刊》 11卷1期 (2009/02) Pp. 73-82

https://doi.org/10.6540/NTJN.2009.1.008

摘要

電腦護理資訊系統標準化可呈現完整的護理記錄。專案人員於臨床照護期間，發現護理人員對於不斷研發上市的抗癌藥物不熟悉，以致於記錄不完整，完整率僅達62.3%，對護理人員進行抗癌藥物認知測驗，正確度僅達23.68%，因而激發改善動機。本專案藉由定期在職教育、公佈抗癌藥物相關資訊及討論、創設「抗癌藥物資料庫」於電腦桌面提供護理人員書寫護理記錄使用作為解決方案，並定期監測記錄完整性。專案執行後，抗癌護理記錄完整性提升至99.5%，抗癌藥物的認知度提升至87.6%，顯示專案措施可有效提升抗癌藥物護理記錄之完整性。

關鍵字

護理記錄 ； 電腦 ； 抗癌藥物

並列摘要

Standardizing the computer nursing information system will enable the completion of a nursing record presentation. During the clinical care period, project personnel discovered nurses' not being familiar with the continuously developing anticancer drugs might result in incomplete records. The integrity ratio was only 62.3%, which did not reach the hospital standard of 90.5%. Moreover, when nurses took the anti-cancer drug awareness test, the accuracy rate was only 23.68%. Therefore, the idea of this improvement project rose. This project uses a regular in-service education program, published anti-cancer drug related information and discussion, and the establishment of an ”anti-cancer drug database” on the computer desktop to provide a solution for the nurses to take down records completely and accurately, and monitor the integrity of the records regularly. After the implementation of the project, the integrity ratio of the anti-cancer drug nursing records improves to 99.5%, and the anti-cancer drug awareness ratio improves to 87.6%, which shows that the project measures are able to effectively enhance the integrity of the anti-cancer drug nursing records.

並列關鍵字

Nursing records ； Computer ； Anti-cancer drug