提昇急診檢傷護理評估記錄完整性之專案

在急診室，搶救病患是分秒必爭的，而一份完整的護理記錄，是護理的品質保證，更是法律上基本的憑據。本單位於90年12月查核100份急診檢傷護理評估記錄，發現書寫時間耗時；記錄內容完整性低及護理人員採用敘述是急診檢傷護理評估記錄滿意度低。經FOCUS－PDCA為架構成立持續性品管小組，由改善急診檢傷護理評估表單、確立指引說明、安排人員在職教育、針對記錄不完整者給予宣導、設定專人檢核，建立定期查核制度，結果顯示：急診檢傷護理評估記錄平均書寫時間由3分鐘縮短為1分鐘25秒，完整性由22%增加為86%，護理人員使用急診檢傷護理評估表滿意度由21.2%提昇為85.9%；並提昇照護品質及促進專業發展。

關鍵字

急診驗傷；護理評估記錄；完整性

並列摘要

In an emergency room, it is important to seize every minutes and seconds to rescue the patients. A perfect organized nursing record is a guaranteed of the nursing care quality, as well as basic legal proof. This proposal was developed based on the FOCUS-PDCA institution and the team for continue quality control was established. When we checked 100 Emergency triage nursing records on December 9,we discovered that it wasted a lot of time to write down and most of the records were incomplete, and few nursing stuffs used the narration type Emergency triage nursing records .For improving the Emergency triage nursing records, we arranged a meeting to explain the plan and educated them about the checking list. The results show that the everage time for recording of the Emergency triage nursing records reduces from 3 minutes to 1 minutes and 25 seconds, the completeness increases from 22 percent to 86 percent, and the satisfaction of nursing Emergency triage nursing records increases from 21.2 percent to 85.9 percent. The proposal can increase the quality of nursing care and promote the professional improvement.