資訊護理紀錄系統導入之使用者評值探討

Study on the Efficiency of a Nursing Documentation Information System

鄭茜如(Chien-Ju Cheng) ； 李亭亭(Ting-Ting Lee) ； 劉介宇(Chieh-Yu Liu) ； 陳孝範(Shiaw-Fan Chen)

《榮總護理》 37卷3期 (2020/09) Pp. 268-278

https://doi.org/10.6142/VGHN.202009_37(3).0006

摘要

護理記錄是護理人員對於病人照護過程所做的記載，紀錄若未整合或反覆謄寫容易產生錯誤，且影響病人安全，故運用資訊科技有助於提升護理紀錄的正確性與完整性，進而整合照護資訊、簡化流程，提升照護品質。本研究目的是資訊科技導入護理紀錄之使用者評值成效。本研究方法一為以資訊系統成功模式為架構之護理紀錄系統成效問卷調查表，進行使用者系統評值，二為分析護理紀錄審查結果於護理紀錄系統導入前後的內容差異。本研究問卷收案143份，各構面得分依序為資訊品質（2.68）、淨效益（2.65）、使用者滿意度（2.55）、服務品質（2.51）、系統品質（2.46），資訊因子與使用者滿意度及淨效益皆呈正相關。護理紀錄於護理措施、出院護理指導及出院護理紀錄於系統導入後紀錄品質明顯提升。結果顯示使用者對於護理紀錄系統導入評價趨於正向，故資訊科技導入時，應以提升資訊因子品質以使系統發揮最好效益；系統導入初期，護理紀錄品質差異可能僅呈現於部分項目，須持續追蹤評值。

關鍵字

護理紀錄 ； 護理資訊系統 ； 資訊系統成功模式

並列摘要

Nursing records are nurse-prepared records of the patient care process. Integration of nursing records is essential for avoiding data repetition and errors that may endanger patient safety. Use of information technology helps to improve the correctness and integrity of nursing records, integrate care information, simplify the process, and improve the quality of care. The purpose of this study was to obtain the evaluations of users and differences in the record review process before and after an information technology intervention. We utilized two approaches: a questionnaire to assess the effectiveness of the nursing record system based on the information system success model for user evaluation, and analysis of the difference in the nursing record review score of hospitals before and after the information technology intervention. The questionnaire contained 143 questions under different categories, namely, information quality, net benefit, user satisfaction, service quality, and system quality; the scores for each category were 2.68, 2.65, 2.55, 2.51, and 2.46, respectively. All information factors were strongly positively correlated with user satisfaction and net benefit. Nursing interventions, hospital nursing discharge instructions, and instruction documentation were significantly improved aspects of record quality after implementation of the information system. The users' perceptions of the information system were positive, suggesting that the quality of information factors should be improved when implementing information technology to ensure that the most favorable outcome is obtained using the system. In addition, improvement in nursing record quality may appear only in some items at the beginning of system deployment, and thus, follow-up evaluations should be continued.

並列關鍵字

nursing records ； nursing information system ； information system success model

參考文獻

于桂蘭、陳迺葒、林萍章(2016)．法律，證據與護理紀錄．臺灣腎臟護理學會雜誌，15(2)，12-20。

于湘梅、徐嫈月、施叔杏、莊馥蓮、曾昭梅、張淑芳(2014)．兒科電子化護理紀錄之改善方案．榮總護理，31(1)，83-92。

宋佩貞、古政元、謝文淮、陳富豪、楊瑛碧(2010)．影響處方箋釋出系統的資訊採用與醫藥分業之關鍵因素分析．台灣公共衛生雜誌台灣衛誌，29(6)，505-517。

李亭亭(2015)．健康照護科技之評值方法介紹．護理雜誌，62(3)，17-22。

李莉鈺、徐建業、蔡宗宏、張正雄、劉滄梧、劉湫美(2012)．癌症醫療品質管理考核資訊系統之評估模式．電腦稽核期刊，(25)，1-15。