運用標準化營養診斷名辭於「營養照護紀錄資訊系統」提升營養照護記錄品質

Using Standard Nutritional Diagnosis in the Nutrition Care Information System Improves the Quality of Nutrition Care Record.

賴秀怡(Hsiu-Yi Lai)

指導教授 ： 楊淑惠

臺北醫學大學/公共衛生暨營養學院/保健營養學研究所/碩士(2011年)

https://doi.org/10.6831/TMU.2011.00081

摘要

美國國家科學研究院醫療研究所提出醫療照護品質的成效評估，可以經由病人健康狀況的改善，以及就執行符合確認的照護流程的程度，作為測量指標。2003年美國營養師協會（American Dietetic Association, ADA）建構了系統化的營養照護流程及模式（Nutrition Care Process and Model, NCPM），指出營養照護流程是經由營養評估、營養診斷、營養介入及營養監控與評值等，連續性的四個步驟所構成，營養診斷是營養照護流程中的核心步驟。本研究運用內建標準化營養診斷名辭的「營養照護資訊系統」，完成具有一致性營養診斷名辭的營養照護紀錄。利用資訊系統建構追蹤病人營養照護介入後的成效評值工具，讓營養照護紀錄可呈現營養師介入後的成果，提升了營養照護紀錄的品質。研究中，分析使用內建標準化營養診斷名詞「營養照護資訊系統」前的住院病人營養會診紀錄資料，發現未使用此系統的營養會診紀錄中，指出病人營養問題的比例未滿五成，即使文件中有寫出營養問題的診斷，同樣的問題所用的營養診斷名辭也沒有一致性，使用內建標準化營養診斷名辭的「營養照護資訊系統」改善了這個問題，可以讓所有營養照護紀錄文件都有使用摽準化的營養診斷名辭及並明確紀錄相關病因及症狀。利用資訊系統的資料庫，營養診斷紀錄的資料可以用來分析住院病人主要的營養問題及造成相關營養問題的原因。分析結果顯示，住院病人的主要營養問題是熱量攝取不足，佔全部照護紀錄的30.9%，尤其是血液腫瘤科的病人，熱量攝取不足的比例高達43%。造成熱量攝取不足的主要原因，是病理或生理因素導致身體能量需求增加或無法攝取足夠的能量。追蹤住院病人營養介入後，77.3%的病人營養問題有獲得改善。運用內建標準化營養診斷名詞於「營養照護紀錄資訊系統」確實可以提升營養照護紀錄品質。

關鍵字

營養照護資訊系統 ； 營養診斷 ； 營養照護流程 ； 營養會診、照護品質

並列摘要

The National Academy of Science’s (NAS) Institute of Medicine (IOM) has defined “The quality performance of providers can be assessed by measuring the following: (a) their patients’ outcomes or (b) the degree to which providers adhere to an accepted care process.” In 2003, the American Dietetic Association (ADA) established a standardized Nutrition Care Process (NCP) and Model were identified as a standardized process for dietetics professionals. The NCP consists of four distinct, but interrelated and connected steps: (a) Nutrition Assessment, (b) Nutrition Diagnosis, (c) Nutrition Intervention, and (d) Nutrition Monitoring and Evaluation. “Nutrition Diagnosis” was the key step of NCP.
The purpose of this study was to establish a nutrition care information system with standard nutritional diagnosis terminology to improve the efficacy of the quality of nutrition care record. There were more than 50% in the nutrition care documents without “Nutrition Diagnosis” before use nutrition care information system with standard nutritional diagnosis. These documents had record of “nutritional problems” in different words to mean the same diagnosis. After using the nutrition care information system with standard nutritional diagnosis nutrition care documents had been record with standard nutritional diagnosis terminology and 77.3% of subject patients had improves their outcome in this study.
To analyze the nutritional problems of subject patients, “Inadequate Energy Intake” was the most common nutrition problem (30.9%) especially in oncology patients (43%), more of its etiology was “pathological or physiological causes that result in increased energy requirements or decreased ability to consume sufficient energy”.
Establishing and using this nutrition care information system with standard nutritional diagnosis terminology could provide more information from nutrition care record and improve the quality of nutrition care record.

並列關鍵字

Nutrition Care Information System ； Nutrition Care Process ； Nutrition counseling ； Quality Control and Efficiency, Nutrition diagnosis

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