護理評估資訊系統使用前後對護理紀錄時間及紀錄品質成效之探討

本研究旨在探討護理評估資訊系統，包含入院護理評估及每日身體評估兩項護理評估系統於使用前後，對於臨床護理人員在完成護理評估紀錄所需時間及紀錄品質之成效。研究採類實驗性前後測設計，研究對象以北部某醫學中心綜合內科與綜合外科病房護理人員。資料蒐集採直接觀察法及回溯性病歷審查法。測量工具是以碼表測量護理評估系統上線前後所需的紀錄時間，另以護理評估紀錄品質查核表進行查核，並以紀錄完成率作為品質指標。研究結果，在紀錄時間部分，入院護理評估上線前共觀察37人次，上線後共觀察24人次，平均紀錄時間由上線前10.5分鐘縮短為上線後8.4分鐘。每日身體評估上線前共觀察28人次，上線後共觀察35人次，平均紀錄時間由上線前1.5分鐘縮短為1.4分鐘，而紀錄時間上線前後皆無統計上顯著差異。在紀錄品質部分，入院護理評估平均完成率由上線前93.5%降低為上線後90.7%，而上線前後無統計上顯著差異。每日身體評估平均完成率由上線前98.1%降低為上線後91.1%，且上線前後有統計上顯著差異。護理評估系統初次導入，護理人員能順利轉換紙本紀錄模式至電腦輸入模式，但需依據各項紀錄品質不完整原因進行系統改善如介面中評估選項位置的連貫性；針對不同專科的有不同的身體評估項目設計，未來將加強人員教育訓練和持續性的紀錄品質監督。

關鍵字

入院護理評估；系統評值；護理資訊

並列摘要

The purpose of this study was to evaluate the nurses' performance before and after nursing admission assessment and daily nursing physical assessment information systems implementation. The study used quasi-experimental research design before and after implementing nursing assessment information systems. The subjects were the nurses in two medical and surgical wards in one medical center in northern Taiwan. Data collection was through direct observation and chart review. The instruments were stopwatches for time measurement and quality checklist for nursing assessment records. The completeness rate was the indicator of nursing records quality. We observed 37 person-times before and 24 person-times after implementing the nursing admission assessment information system. The average observation time was decreased from 10.5 minutes before to 8.4 minutes after. We also observed 28 person-times before and 35 person-times after implementing the daily nursing physical assessment information system. The average observation time was decreased from 1.5 minutes before to 1.4 minutes after. There was no statistical significance before and after implementing both systems. In the quality of records, the average of completeness rate was decreased from 93.5% before to 90.7% after implementing nursing admission assessment information system. There was no statistical significance. The average completeness rate decreased from 98.1% before to 91.1% after implementing the daily nursing physical assessment information system. There was statistical significance. The two information systems were smoothly implemented in the wards; however, some improvements should be done, such as the consistency of every assessment item in the system user interface and customized assessment items instead of general assessment for different clinical units. The nurses' education should be enhanced and nursing managers should regularly monitor the quality of nursing records in the future.

並列關鍵字

nursing admission assessment ； daily nursing physical assessment ； system evaluation ； nursing informatics

被引用紀錄

高鳳蘭（2015）。護理人員對護理紀錄電子化資訊系統之接受度與系統使用成效之相關性探討-以某精神專科醫院為例〔碩士論文，長榮大學〕。華藝線上圖書館。https://doi.org/10.6833/CJCU.2015.00013

吳律嫺、李麗紅、張淑真（2022）。以質性研究法探討護理人員面對護理資訊系統中斷的處理經驗。彰化護理，29(4)，2-15。https://doi.org/10.6647/CN.202212_29(4).0002

林信源（2015）。醫護專業人員與一般民眾分享健康資訊比較研究：以臉書為例〔碩士論文，義守大學〕。華藝線上圖書館。https://doi.org/10.6343/ISU.2015.00395

姜瑤娟、李亭亭（2018）。護理人員使用跨團隊照護資訊系統的成效探討。護理雜誌，65(4)，49-59。https://doi.org/10.6224/JN.201808_65(4).08

何玉瑛、陳怡伶、陳永娟（2020）。降低住院血液透析病人之透析排程缺失率。榮總護理，37(3)，252-259。https://doi.org/10.6142/VGHN.202009_37(3).0004

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護理評估資訊系統使用前後對護理紀錄時間及紀錄品質成效之探討

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