精神復健病房護理記錄電子化系統之成效評價

The Efficacy of Nursing Electronic Recording at Psychiatric Rehabilitation Unit

李鳳嬌(Feng-Chiao Li) ； 高鳳美(Feng-Mei Kao) ； 邵文娟(Wen-Chuan Shao) ； 吳聖良(Shang-Liang Wu) ； 林梅珠(Mei-Jue Lin)

《精神衛生護理雜誌》 7卷1期 (2012/10) Pp. 11-22

https://doi.org/10.6847/TJPMHN.201210_7(1).0002

摘要

樣本醫院於97年建構精神專科護理記錄電子化及支援軟體系統，期能改善人工書寫的費時費力，減少錯誤或字跡凌亂的問題。故本研究目的在比較精神專科手寫與電子化護理記錄間正確性、完整性、與書寫時間之差異，作為推廣護理記錄電子化之依據，希能提升護理記錄的正確性與完整性。採立意取樣選取某精神專科教學醫院6個復健病房之護理人員共計36人。評價設計採類實驗研究之二組時間序列前、後測設計；分實驗組、對照組，自98.7.16至99.3.31止，每月收集一次當月護理記錄正確性、完整性、書寫時間為效果評價指標。樣本屬性，教育程度屬大學居多（佔55.6%），專業進階N2以上佔55.6%；工作平均9.8年。實驗組在電子化後，從第二個月至第四個月間，正確性與完整性進步顯著高於對照組；正確性最高達97.8%、完整性最高達96.5%。在書寫總時間方面：雖前測時實驗組（9.69分）較對照組（4.48分）多花費5.2分，但至第三個月及第七個月時，實驗組均有顯著下降；降幅分別達24.5%及42.2%（每筆平均時間為5.6分），而該段期間對照組之時間卻顯著上升。由於統計顯示護理記錄電子化效果良好，故應可全面實施至其他12個病房。另，建議其他精神醫院或綜合醫院精神科之慢性病房亦可考慮實施此模式之護理記錄電子化。

關鍵字

精神專科醫院 ； 護理記錄電子化 ； 成效評價

並列摘要

Background: In the past, the production of psychiatric nursing records was learned and performed under supervision during busy psychiatric practice. As the hand writing of records is time-consuming and great effort is required to keep records up-to-date, we have been forced to seek establishing a computerized nursing record system and its supported software since 2008. Writing errors and unclear hand writing are also major problems affecting the validity and integrity of nursing records. The consumption of large amounts of time for writing nursing records takes up most of the time on patient care and the quality of patients' care. Purpose: This purpose of this research is to suggest the alternative way of computerized-record-making method instead of the traditional and strenuous hand-writing method in order to satisfy the need of more accuracy and integrity of medical records with the least time consumption. Methods: The research instruments include sample picks, selections of nursing staff from six recovery rooms with totally 36 people. The appraisal design picks a second group of time series different from the experimental one to survey the ideas between the pre-test and posttest. Then we arranged an experimental group and a contrastive group, and collected handwriting records of nursing staff separately from March 31, 2010, to July, 16, 2009 every month for examine their accuracy, integrity, and the written time spent on for the effect evaluation indicator. Results: The research sample attributes: the faculty majority with university backgrounds in the education level aspect accounts for 55.6%, with the specialty enters above step level N2 accounts for 55.6%, and working experience on an average of 9.8 years. The experimental group after computerized-record implementation, from the second month to the fourth month, shows the accurate and the complete progress scope obviously higher than the control group. The highest accuracy can reach 97.8% and the integrity 96.5%. As to the hand-writing consumption, the experimental group of nurses produce the records before the test, spending average 9.69 minutes in comparison with the control group's spending 4.48 minutes, with the difference of 5.20 minutes more, but not until the 3rd month and the 7th month, the experimental group's total spending time have a remarkable drop. The range of the fall respectively reaches 24.5% and 42.2% (each represents the hand-writing-spending time is 5.6 minutes), and during the period, the control group's total spending time still continues to rise obviously. Conclusion: Since the evidence demonstrated that nurses can produce the records by using the computerized system with better effects, therefore the other 12 hospital wards are suggested to have the record comprehensibly implemented with computerization. Of course, we'd like to propose all the psychiatric departments' wards in General hospitals can also consider using computerized records.

並列關鍵字

Psychiatric Hospital ； Nursing Records Computerization ； Result Appraisal