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某精神專科醫院護理記錄電子化系統之發展

Developing a Computerized System Development of Nursing Records in a Psychiatric Hospital

摘要


繁忙的醫療情境中,精神專科護理記錄藉由學習或臨床經驗傳承,但因人工書寫費時費力,缺乏時效性,也常發生書寫錯誤或字跡凌亂的問題,以致影響護理記錄的正確性與完整性,更影響照護病人時間及品質。故本專案研討主要目的為建構精神專科護理記錄電子化及支援軟體系統。本案收集病歷紙本資料,回溯分析手寫護理記錄之相關內容,包括資料收集來源、過程、結果,最後建立資訊系統等三階段。專案過程以焦點記錄法為主軸,參考北美護理診斷協會(North American Nursing Diagnosis Association; NANDA, 1988)所公布護理診斷之項目為指標,依序F、D、A、R方式呈現電子化護理記錄。 專案執行十八個月,完成護理記錄內容包含精神科常用焦點問題主題(Focus)共45個、護理指導18個、護理計畫評值28個三種書寫格式,選用Microsoft Access為後端資料庫,完成軟體建構。期間完成三次測試後執行試辦計畫,作為過程結果評價指標,期待電子化系統使用能更臻完整。此護理記錄電子化內容修訂與建構,由資深精神專科護理人員組成的團體所完成,為一項重大的建構工程,期許減輕臨床護理繁重的工作負擔,作為精神專科護理記錄之重要工具。

並列摘要


The production of psychiatric nursing records was learned and performed in the past under supervision during busy psychiatric practice. The hand writing of records was time-consuming and great effort was required to keep records up-to-date. The use of large amounts of time for writing nursing records affects time spent on patient care and hence also the quality of patient care. Writing errors and unclear hand writing are also major problems affecting the validity and integrity of nursing records. In this study, we sought to establish a computerized nursing record system and supporting software. We collected nursing records written by nurses from chart records. We retrospectively analyzed these hand-written nursing records and their contents, including sources of data collection, procedures and results, ultimately establishing a three-section information system. During the study procedure, we used nursing focus as a primary axis. We also consulted and took as our standards the North American Nursing Diagnosis Association's (NANDA) published nursing diagnostic characteristics, presenting our computerzing nursing records in the order F, D, A, R. The study lasted for 18 months, involved 64 meetings and the expenditure of 104hrs, or a total of 472 hours/person. We completed a nursing records software including 45 psychiatric nursing focuses, 18 nursing directories, 36 nursing plans, and evaluations in three written forms. We chose Microsoft Access as our data bank. We completed three pilot tests to serve as standards for the results of the procedure. We hope the software will be perfect in integrity. The nursing records software was completed by a group of many senior psychiatric nurses. It was an important project for reducing the clinical nursing burden and an important tool for psychiatric nursing records.

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%2fCJCU.2015.00013
林育珊(2012)。建置與評值精神衛生護理過程系統〔碩士論文,臺北醫學大學〕。華藝線上圖書館。https://doi.org/10.6831%2fTMU.2012.00038
彭治豪(2017)。任務科技配適模式探討長照管理資訊系統使用成效之研究〔碩士論文,中山醫學大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0003-1408201711070200

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