A Performance Improvement Project for Orthopedic Nursing Documentation
張秀娟(Shiou-Chuan Chang)；張育婷(Yu-Ting Chang)；劉玉玲(Yu-Ling Liu)；章淑娟(Shu-Chuan Chang)
護理紀錄 ； 骨科 ； 改善方案 ； nursing records ； orthopedic ； improvement project
|Volume or Term/Year and Month of Publication||
10卷2期（2009 / 08 / 01）
121 - 130
Nursing documentation is an important part of medical records and must be accurate, complete, and diagnosis-specific. Nursing staff in an orthopedic unit is often confused by duplicate nursing charting. This project aimed to improve nursing documentation in an orthopedic unit and to increase nurse satisfaction in charting thereafter. Data were collected in March 2007. Several problems were identified: (1) contents of nursing records were duplicated and incomplete; (2) nursing documentation forms were complicated and time-consuming to complete; (3) the ”principle of nursing documentation” was generalized and lacked diagnosis-specific details; (4) the score of nurse satisfaction on nursing charting was 2.79 out of 5. The principle of nursing documentation was redefined. The contents of nursing records were redesigned, reformatted, and simplified. The post survey indicated improvement in nursing charting as follows: (1) completeness of chart contents raised to 96%; (2) time spent on nursing documentation was reduced from 279.03 sec/case to 237.19 sec/case; (3) nurse satisfaction was 4.19, much higher than the previous score. The research showed obvious improvement in the contents of nursing charting, time spent on charting, and nurse satisfaction on charting. The research method can be applied in other units where colleagues would like to improve nursing documentation.
醫藥衛生 > 社會醫學