TPR記錄電子化之臨床效益評值

Evaluation of the Clinical Effectiveness of Electronic Documentation of T. P. R.

陳琍(Li Chen)

《志為護理-慈濟護理雜誌》 1卷4期 (2002/12) Pp. 65-72

https://doi.org/10.6974/TCNJ.200212.0065

摘要

人工抄錄生命徵象數值不僅耗時且記錄品質不易控管。本專案實施主要目的在節省常規性記錄（如體溫、脈搏、呼吸、血壓等）工時，並提升記錄內容的正確性及完整性。結合個人數位助理器與醫院資訊系統，專案實施6個月後檢測：全院平均每日節省TPR記錄工時6.2小時，每月可節省23個工作天人力。TPR記錄正確率、完整率亦有改善。TPR記錄正確率由91.7%提升至100%；TPR記錄完整率由86.1%提升至100%。專案研究顯示某醫學中心護理人員對PDA使用在年齡、服務年資、職稱上有顯著差異，護理人員對PDA效能持肯定態度。專案實施後可節省常規護理記錄工時並提升記錄品質。

關鍵字

臨床效益 ； 電子化 ； 個人數位助理器 ； 體溫脈搏呼吸記錄

並列摘要

The manual documentation of vital signs, not only waste time, but also show difficult to control the quality of record The purpose of this project was to save time of documentation and improve the complete & accurate recording percentage of TPR. The project was conducted by linking the hospital information system with a Personal Digital Assistant (PDA) for recording of TPR. After 6 months of implementing this project, averagely saving 6.2 hours in documentation of TPR daily was measured. It was equal to save 23 FTE (full time equivalent) per month in the hospital. The researcher also found that documentation is more accurate and complete. The percentage of accuracy in TPR record increased from 91.7% to 100%. The completeness in TPR record increased from 86.1 % to 100%. Nurses' PDA-related attitudes generally were positive. There were significant difference among age, length of service, job title at one of eastern medical center. The results showed that this project not only save time in documentation of TPR but also improve the quality of TPR record after implementation of the project.

並列關鍵字

clinical effectiveness ； electronic ； Personal Digital Assistant ； temperature ； pulse ； respiration record