提升某醫院內科病房護理師電子簽章完成率

Improvement of the Completion Rate of Electronic Signature by Nurses in the Electronic Health Record Making at an Internal Medicine Ward

曾瓊瑩(Chiung-Ying Tseng) ； 黃琬珺(Wan-Chun Huang) ； 黃代泱(Tai-Yang Huang) ； 胡淑惠(Shu-Hui Hu)

《病歷資訊管理》 13卷1期 (2014/07) Pp. 35-44

摘要

電子病歷的完整性、真確性與法律效力要經由護理人員醫事憑證IC卡完成電子簽章，才可確保。本單位高達96%的護理師曾有未於病歷完成後24小時內完成簽章之紀錄，於2011年1月至7月統計，電子簽章未於病歷完成後24小時內完成的不完整率以2011年7月最高達12.6%（完成率87.4%），相較護理部總平均值0.01%，明顯高出許多。經探討護理師未於病歷完成後24小時內完成電子簽章導因為；一、人員面：護理師無如期完成電子病歷簽章重要性認知、無下班前完成電子簽章習慣、小組長未落實稽核電子簽章；二、制度面：電子簽章規範不明確；三、設備面：電子簽章設備不足。改善方法：提升電子病歷簽章重要性認知、培養完整電子簽章行為、修訂規範與落實查核、增加電子簽章設備等，改善後護理師於病歷完成後24小時內完成電子簽章完成率，由87.4%提升至100%，提升單位護理師參與維護病人病歷資訊安全，保障病人就醫的權益。

關鍵字

電子病歷 ； 電子簽章 ； 病人安全

並列摘要

In order to assure the integrity, accuracy and legality of the content of an electronic health record (EHR), the nurse who makes the record has to add her electronic signature to the record using her own medical identity IC card. According to our record, as many as 96% of this unit's entire nursing staff have each failed at least once before to do the required electronic signature within 24 hours after the EHR was keyed in. In the period between January and July 2011 that we studied, the incomplete rate of EHR of this unit reached a peek of 12.6% in the month of July (or a complete rate of 87.4%) due to failing to add electronic signature within 24 hours after the recording, significantly higher than the average rate of the rest of the Nursing Department, which was only 0.01%. This study reveals the reasons for the high incomplete rate are as follows: 1. Personnel aspect: the nurses were not aware of the importance of adding the electronic signature in time; they were not accustomed to do the electronic signature of their EHR makings before getting off their duty at the end of the day; and their team leader failed to check if the electronic signature was done in time. 2. Systemic aspect: the electronic signature was not clearly demanded in the regulations. 3. Equipment aspect: insufficient access to the electronic signature facility. Measures for improvement included: to increase the nurses' awareness of the importance of electronic signature, to develop the nurses' habit of adding electronic signature to the EHR making, to revise SOP regulations to include electronic signature making and checking, and to make sufficient electronic signature devices available. After the improvement program had been implemented, the results showed that: The complete rate of electronic signature by our nurses increased from 87.4% to 100%. The project not only solved the problem of electronic signature by nurses in EHR, but also increased the involvement of the nurses in the patient protection through better safety in medical information, and enhance their rights of medication access.

並列關鍵字

Electronic Health Record (HER) ； Electronic Signatures ； Patient Safety