提升加護病房電子病歷護理交班之完整性

Promotion of Electronic Medical Records Integrity of Nursing Handover in Intensive Care Unit

林慧君(Hui-Chun Lin) ； 陳俞君(Yu-Chun Chen) ； 林琪馨(Chi-Hsin Lin)

《志為護理-慈濟護理雜誌》 12卷1期 (2013/02) Pp. 77-87

摘要

行政院衛生署於2000年起開始推動電子病歷，使得醫護人員需改以電子病歷方式來傳遞交班訊息，因此，過程中當交班訊息的傳遞不正確、中斷、遺漏或不完整，將影響到病人治療方針，更甚會危害到病人生命安全。2010年3月1日至3月8日查核護理人員使用電子病歷交班完整率僅44%，分析原因為瀏覽電子病歷時頁面多，以致介面轉換慢、對電子病歷操作不熟悉、對交班內容認知不同、單位無稽核制度和缺乏電子病歷護理交班規範。經2010年3月1日至5月14日將舊式紙本交班卡和電腦作結合、設計交班專屬頁面、舉辦電子病歷上線需知、宣導交班重要性及內容、制訂稽核制度和電子病歷護理交班規範等措施後，交班完整率提升為90%。此專案使護理人員更能有效率獲得正確交班訊息、縮短交班時間，也提供了病人安全及最佳的照護品質。

關鍵字

加護病房 ； 電子病歷 ； 護理交班

並列摘要

The medical personnel have used electronic medical records (EMR) to transmit messages since Taiwan Health Department promoted EMR in 2000. Therefore, the handover-induced inaccurate, disconnected, missing, or incomplete messages would affect treatment guidelines and even endanger patient life. With just 44% of the nurse-handover integrity from March 1 to 8, 2010, the reasons were analyzed: excessive pages in electronic medical records slowed down interface transmissions; the unfamiliarity with EMR application; different cognitions in handing over with EMR; absence of auditing system and standard criteria for electronic handover. Through computerization of the traditional paper shift card from March 1 to May 14, 2010, and the contrived exclusive handover interface, on-line EMR instruction training, promotion of handover EMR importance, and regulation of EMR audit system and handover standard, 90% handover EMR integrity was achieved. The project was helpful to enable nurses to obtain correct handover EMR procedure more efficiently, shorten handover time, and provide safety and best care quality for patients.

並列關鍵字

electronic medical records ； Intensive Care Unit ； nursing handover