建置某安寧病房護理資訊系統之專案

研究目的：資訊化護理紀錄較紙本紀錄更能進行訊息傳遞，經調查發現紙本護理紀錄使用者滿意度僅33.3%，故成立專案小組。研究方法：經分析發現主要問題為：紙本紀錄無法修改導致畫面雜亂、單張種類多，不符合書寫記錄需求；交接班時需逐頁翻閱各項紀錄，易遺漏照護訊息。結果：經執行專案對策，建置安寧護理紀錄資訊系統與擬定「安寧護理紀錄」系統功能、整合紀錄單張，規劃「生理問題護理紀錄表」的格式、增設護理資訊紀錄連結功能、執行護理紀錄資訊系統使用者在職教育後，單位護理人員對護理紀錄撰寫滿意度提升至95.8%。結論：建置安寧護理資訊紀錄後能整合紀錄單張，運用護理紀錄資訊系統能讓紀錄內容清楚且一目了然；交接班時也不會遺漏重要照護訊息，符合護理人員撰寫紀錄與交接班需求，有效提升使用者滿意度及工作效益。

關鍵字

護理資訊系統；安寧護理紀錄

並列摘要

Background: The electronic nursing record is a lot more capable of sending information than the handwritten record. After conducting an investigation, we found that user's satisfaction of the handwritten record was only 33.3%. Methods: Through some analysis, the main problem were found that the handwitten record could not be modified, resulting in messy pages, various kinds of single record sheets were not integrated for the staff to write the records easily. Moreover, after a handover was completed, all the records had to be read page by page, and it was easy to miss some caring document. Results: The following are implementing countermeasures: establishing the electronic nursing record system, integrating each single record sheet, planning the ＂Physical Problem Nursing Record Form＂ format, adding the function of the Nursing Information Record Link and performing in-survice education for users. Finally, the overall user satisfaction increased to 95.8%. Conclusions: After the electronic nursing record system was set up, the records in each single sheet could be integrated. Using the electronic nursing record system made the records clear and the staff understood them fully at one glance. The important care messages wouldn't be missed during the nurse-to-nurse handover. It also increased the user's satisfaction and work efficiency effectively.