提升產前護理指導紀錄資訊化完整率

Improvement in the Information Integrity Rate of Computerized Prenatal Education Records

楊淑蕙(Shu-Hui Yang) ； 賴美玲(Mei-Ling Lai) ； 吳宛珊(Wan-Shan Wu) ； 莊昭華(Chao-Hua Chuang)

《彰化護理》 26卷2期 (2019/06) Pp. 120-130

https://doi.org/10.6647/CN.201906_26(2).0013

摘要

產前護理指導紀錄傳遞孕婦接受連續性照護與指導重要的資訊，然而開始推動產前護理指導紀錄資訊化時，常出現紀錄不完整，查核發現完整率僅達72%，故成立專案小組藉以提升產前護理指導紀錄資訊化完整率。經探討產前護理指導紀錄資訊化執行情形，發現紀錄不完整原因有：未落實執行產前護理指導時程內容、缺乏紀錄書寫作業標準、無稽核機制及查詢歷史紀錄內容複雜耗時。綜合上述原因單位自2016年4月至2017年2月進行改善策略，含括舉辦紀錄稽核評分暨書寫方法說明會、提供常見缺失查檢表單範例、製作紀錄叮嚀小卡、增設紀錄書寫作業標準、建立紀錄稽核機制、資訊簡化紀錄查詢步驟、歷史紀錄點選方式說明及個別輔導等措施。經改善策略執行後，產前護理指導紀錄資訊化完整率提升至100%。期望藉此專案推行之經驗，提供臨床推行產前護理指導紀錄資訊化執行過程之參考。

關鍵字

產前 ； 資訊化 ； 護理指導紀錄 ； 完整率

並列摘要

Prenatal education records show important information that pregnant women receive continuity of care and education. However, after the implementation of the computerized prenatal education record, the record was often incomplete, and the integrity rate of the information was merely 72%. Therefore, an ad hoc group was set up to improve the information integrity rate of the prenatal education records. It was found after discussion that the reasons causing the incomplete computerized information of prenatal education records included the unimplemented prenatal education of the contents in accordance with the guidance schedule, lack of standard for writing when it comes to record keeping, lack of an audit mechanism, and the complicated and time-consuming process for past information retrieval. Targeting at the above reasons, our unit implemented the improvement strategies from April, 2016 to February, 2017. The strategies included holding an illustration meeting for documentary audit scoring and record keeping, providing a checklist for common defects, making reminders for record keeping, setting up writing standard for record keeping, establishing a record audit mechanism, simplifying the steps for querying records, explanation of historical record selection methods, and individual counseling. After the implementation of these strategies, the integrity rate of computerized prenatal education records reached 100%. It is hoped that the experience of this project implementation can serve as a reference for the implementation of computerized prenatal education record in the clinical context.

並列關鍵字

prenatal ； computerization ； nursing education record ； integrity rate

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