運用資訊系統降低血液透析記錄不完整率

黃秀燕; 徐紫娟; 張玉婷

doi:10.29494/LN.201709_18(3).0009

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P98 - 112

医药卫生 > 预防保健与卫生学
医药卫生 > 社会医学

DOI： 10.29494/LN

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运用资讯系统降低血液透析记录不完整率

Using Information Systems to Decrease the Percentage of Incomplete Hemodialysis Records

黄秀燕(Hsiu-Yen Huang) ；徐紫娟(Tzu-Chuan Hsu) ；张玉婷(Yu-Ting Chang)

领导护理； 18 卷 3 期 (2017 / 09 / 01) ， P98 - 112

繁体中文 DOI： 10.29494/LN.201709_18(3).0009

血液透析；护理纪录；资讯系统； hemodialysis ； nursing records ； information systems

2 个人觉得这篇文章赞

摘要 │ 参考文献 (18) │ 被引用文献 (2) │ 国际计量

摘要〈TOP〉

并列摘要〈TOP〉

Complete nursing records enable effective communication between medical personnel and can improve the maintenance of patient care quality. Our Hemodialysis Center, which prepared hemodialysis records by hand, regularly experienced incomplete records. Therefore, a project team conducted a hemodialysis record survey and found that 19.5% of hemodialysis records were incomplete. We subsequently conducted interviews and generalized the results, from which the causes of incompletion were identified: (a) the time for providing and recording the hemodialysis care overlapped each other, which renders the nursing personnel to have insufficient time to record properly; (b) nursing personnel did not make records immediately after the hemodialysis treatments and often forgot to complete them; (c) there were multiple types of forms that were not integrated and evaluated for effectiveness; (d) the hemodialysis record forms were small and easily missed; and (e) the nursing personnel were not provided with a standard for recording their observations during the process. To alleviate these problems, the process of recording hemodialysis observations were simplified, record-writing standards were formulated and implemented, a hemodialysis record information system was created, programs for continuing education on hemodialysis observational recordings were hosted, evaluation times of the information system were scheduled, and incentives for using t he information system were implemented. After the aforementioned measures were followed, the percentage of incomplete hemodialysis records decreased from 19.5% to 3.8%. By implementing the project, we improved the incompletion rate of hemodialysis records and elevated patient safety as well as the care quality of hemodialysis patients.

参考文献 ( 18 ) 〈TOP〉

邓庆华,郑雅中,陈素根,李宜静,张胜立,陈颖从,柴怡茜(2014)。智慧化健康照护创新系统之应用和综合效能。医务管理期刊，15(2)，128-149。
连结：
Buntin, M. B.,Burke, M. F.,Hoaglin, M. C.,Blumenthal, D.(2011).The benefits of health information technology: A review of the recent literature shows predominantly positive results.Health Affairs,30(3),464-471.
Frimpong, J, A.,Jackson, B. E.,Stewart, L.M.,Singh, K.P.,Rivers, P, A.,Bae, S(2013).Health information technology capacity at federally qualified health centers: a mechanism for improving quality of care.BMC Health Services Research,13(35),1-12.
Garrcik, R.,Kliger, A.,Stefanchik, B.(2012).Patient and facility safety in hemodialysis: opportunities and strategies to develop a culture of safety.Clinical Journal of the American Society of Nephrology,7(4),680-688.
Hayes, B.,Douglas, C.,Bonner, A.(2015).Work environment, job satisfaction, stress and burnout among haemodialysis nurses.Journal of Nursing Management,23(5),588-598.

被引用文献 ( 2 ) 〈TOP〉

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