- 期刊
- OpenAccess
提升內科加護病房護理病歷書寫完整性之專案
Project to Improve the Completeness of the Writing of Medical Records in the Medical Intensive Care Unit
摘要
背景：病歷為醫療團隊溝通的工具是維護病人健康的基礎，亦是一直以來評鑑的重點。2015年第二季本單位的護理病歷書寫完整性為78.5%，為全院末數第5名。目的：提升單位內護理病歷書寫之完整性。方法：分析不完整原因包括護理病歷種類太多、不清楚審核標準、未及時掌握新規定、未曾舉辦病歷書寫相關教育課程等。於2015年10月1日至2016年6月30日執行期間，由專案小組提出增加每月審核份數及審核者，並舉辦共識營和在職教育、製作常見缺失檢查表及簡化病歷書寫流程等。結果：經執行九個月後，2016年6月完整性可達到93.1%，顯示經專案實施後，不僅可有效改善護理病歷完整性，更能提升醫療照護品質。結論：本專案透過新增單位病歷審核人員及舉辦共識營、執行單位住院病歷自審、簡化護理病歷書寫流程及舉辦相關教育課程等相關改善措施介入，使本專案能順利達成目標。持續在單位執行中，希望可以繼續提升單位病歷書寫的完整性，進而改善醫療品質。
並列摘要
Background: The medical record is a communication device for medical teams. It is the foundation for maintaining the health of patients. It is also the main element of the hospital accreditation. In the second quarter of 2015, the Medical Intensive Care Unit (MICU) writing completeness of the nursing medical records was 78.5%, which was the fifth lowest in the hospital. Objective: Improve the completeness of nursing medical records in MICU. Methods: Analysis the cause which include too many types of nursing records, unclear review standards, failure to grasp new regulations in a timely manner, no education courses related to medical record writing, etc. During the implementation period from 1 October 2015 to 30 June 2016, the task force proposed to increase the number of monthly audits and reviewers, held a consensus camp and continuing education, made common deficiencies checklists, and simplified the process of writing medical records. Results: After nine months of implementation, the completeness of nursing medical records reach 93.1% in Jun 2016. The implementation of the project improve the completeness of nursing medical records and the quality of medical care. Conclusion: Through increase the medical record reviewer in the unit and held consensus camp, implement self-assessment of nursing medical records, simplified the process of writing medical records and held continuing education, our project successfully achieve its goals. We continue to implement the project in the MICU to improve the completeness of nursing medical records and the quality of medical care.
參考文獻
延伸閱讀
- 彭沛語、鄭秋子、李映春、石惠美、李夢英、吳寶媛（2018）。提升恢復室護理人員執行護理記錄書寫完整性之改善專案。志為護理-慈濟護理雜誌，17(5)，101-112。https://www.airitilibrary.com/Article/Detail?DocID=16831624-201810-201810230007-201810230007-101-112
- 李佳倫、任淑玲、陳淨棋、陳美杏（2013）。提升某內科病房N2護理人員比率之專案。馬偕護理雜誌，7(1)，52-62。https://doi.org/10.29415/JMKN.201301_7(1).0006
- 陳思怡、翁妙妃、李惠雯（2020）。提昇護理人員護理記錄書寫完整率之專案。安泰醫護雜誌，26(1)，51-66。https://www.airitilibrary.com/Article/Detail?DocID=18111955-202006-202006040006-202006040006-51-66
- 陳秋珍、胡悛愉、王美惠、林佩昭、陳淑惠（2021）。提升外科專科護理師病歷紀錄正確性之改善專案。台灣專科護理師學刊，8(1)，50-59。https://www.airitilibrary.com/Article/Detail?DocID=P20150413001-202106-202108100010-202108100010-50-59
- 薛錦滿、翁麗真、酒小蕙、許美治（2020）。Improvement in Efficiency of Uploading Data of Vital Parameters Onto Electronic Medical Records Among Outpatients。志為護理-慈濟護理雜誌，19(4)，91-101。https://www.airitilibrary.com/Article/Detail?DocID=16831624-202008-202008240012-202008240012-91-101