運用臨床路徑資訊系統降低護理人員書寫護理紀錄時間

Application of Clinical Pathway Information System to Reduce Time to Write Nursing Records

10.6142/VGHN.202209_39(3).0007

黃曉萍(Sheau-Pyng Huang)；張美玉(Mei-Yu Chang)；侯慧明(Hui-Ming Hou)；張峰玉(Fung-Yu Chang)；張碧華(Pi-Hua Chang)；朱莉螢(Li-Ying Ju)

護理臨床路徑 ； 護理紀錄 ； 護理資訊系統 ； nursing clinical pathway ； nursing record ； nursing information system

榮總護理

39卷3期（2022 / 09 / 01）

282 - 289

繁體中文

2020年調查護理人員完成新病人護理評估、護理計畫、護理紀錄及出院計畫的紀錄時間平均約26.3分鐘，顯示護理人員書寫入院相關護理紀錄耗時。本專案於2020年10月1日至2021年12月31日，經由現況分析確認書寫護理紀錄耗時的5個問題點，分別是：逐字輸入速度慢、新進人員不熟悉健康問題、害怕遺漏反覆修改、護理計畫頁面步驟繁瑣、電子評估表單種類多。藉由訂定護理臨床路徑一頁式表單、建置護理臨床路徑勾選式表單、設定電子評估表單超連結、舉辦教育課程後，護理人員書寫護理紀錄平均時間由26.3分鐘降低至14.7分鐘，改善幅度為44.1%，達成專案目的。本專案運用臨床路徑資訊系統整合護理過程的頁面，減少護理人員書寫護理紀錄時間，進而提升護理人員滿意度。

In 2020, we determined that the average time spent writing nursing records by nursing staff, including new patient assessments, health problem records, and discharge plans, was 26.3 minutes. From October 1, 2020, to September 30, 2021, nursing record writing was studied. Five problems causing excessive time to be spent writing nursing records were identified: slow word-by-word input speed, unfamiliarity of new nurses with health problems, repeated revisions because of fear of omission, complicated nursing plan writing protocols, and an excessive number of electronic assessment forms. The following time-saving solutions were identified: 1. Development of a one-page nursing clinical pathway form; 2. development of a checkbox nursing clinical pathway form; 3. setting the hyperlink of the electronic assessment form; 4. providing classes for nurses. The average time spent writing nursing records was reduced from 26.3 to 14.7 minutes, and the rate of improved nursing record writing time was 44.1%. These results met the prespecified target values. This project used the clinical pathway information system to integrate the various nursing record documents; as a result, nursing record writing time was reduced, and the satisfaction level of the nursing staff increased.

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