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提升透析電子護理記錄完整性之專案
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提升透析電子護理記錄完整性之專案
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Journal Article
提升透析電子護理記錄完整性之專案
2019
Overview
背景：完整的透析電子護理記錄是呈現護理照護過程與品質重要的依據，更是醫療團隊間重要的溝通橋樑。經現況分析，發現護理人員對透析電子護理記錄系統操作介面不熟悉、缺乏系統操作教育訓練、透析電子護理記錄系統設計不佳、缺乏透析電子護理記錄書寫指引，及缺乏透析電子護理記錄書寫稽核制度，導致透析電子護理記錄書寫之完整性僅58.2%。目的：提升透析電子護理記錄完整性大於90%。解決方案：修改透析電子護理記錄系統、建置透析電子護理記錄片語範例、製作透析電子護理記錄操作手冊、進行系統操作在職教育、執行記錄書寫臨床情境模擬演練與透析資訊護理師制度，及落實透析電子護理記錄稽核制度。結果：透析電子護理記錄完整性提升為96.0%；護理師書寫記錄時間由平均21分35秒縮短至8分15秒。結論：良好的資訊系統確實有效提升透析電子護理記錄完整性，也縮短記錄時間，有助於確保透析病人之照護品質。
