提昇某區域醫院急診護理記錄之完整率

The Improvement of the Completion Rate of Nursing Record at a Regional Hospital Emergency Room

林枝蓉(Chih-Jung Lin) ； 廖好蘋(Hao-Pwg Liao) ； 何帥穎(Shuai-Ying Ho)

《北市醫學雜誌》 5卷6_S期 (2008/12) Pp. 683-691

https://doi.org/10.6200/TCMJ.2008.5.6.12

摘要

本專案旨在提升急診護理記錄完整性，以建立交班規範。小組成員收集護理科2006年12月品管組稽核「急診護理記錄」結果：護理記錄完整率僅78.02%，本單位2007年1月份收集300份急診護理記錄完整率僅76.03%。導致護理記錄完整率低之主因為：護理人員對紀錄內容認知標準不同、缺乏交班工具、新進人員缺乏在職訓練及未修訂標準。經由宣導其重要性、表單內容及書寫的標準程序、建立轉診及交班查檢表等方案介入後，急診護理記錄完整率由76.03$提升至90%以上，進而提升交班完整性，減少衝突，增進病人照護品質。

關鍵字

急診 ； 護理記錄 ； 照護品質

並列摘要

The objective of this project was to improve the integration rate of nursing records in an emergency room and then establish inter-unit report guidelines. 300 nursing records from an emergency room (ER) were evaluated by our team in the fourth quarter of 2006. After analysis, results were shown to be 78% and 70%. In addition, the transfer of information (both written and oral) via inter-unit reports was also seen as a problem. The main causes of a lower integration rate included: no standardization of nursing record content, a lack of an inter-unit report format, inadequate on-the-job training for new nurses and no revision of a standard operating procedure (SOP). Improvements were subsequently made by impressing upon the nurses the importance of complete and accurate nursing records, revising the content of the nursing record format, and building a check list for inter-unit transfer of information. Finally, the integration rate of our nursing records rose from 76% to 95%, quality of patient care increased and conflicts between different units decreased.

並列關鍵字

emergency, nursing records, nursing care quality ； inter-unit reports