運用資訊系統降低血液透析記錄不完整率

Using Information Systems to Decrease the Percentage of Incomplete Hemodialysis Records

10.29494/LN.201709_18(3).0009

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

血液透析 ； 護理紀錄 ； 資訊系統 ； hemodialysis ； nursing records ； information systems

領導護理

18卷3期（2017 / 09 / 01）

98 - 112

繁體中文

正確完整的照護紀錄，有利於醫護溝通、維持病患照護品質。本院血液透析中心手寫透析紀錄常有遺漏問題，經專案小組進行透析紀錄查檢，發現紀錄不完整率為19.5%，經由訪談、歸納，確立主要原因為：透析照護和紀錄時間重疊，導致護理人員來不及寫；透析中護理人員未隨手記錄，事後又忘記補記錄；表單未整合，無固定評估時間；透析紀錄表格細小，容易遺漏；依個人判斷書寫處置紀錄。藉由簡化血液透析紀錄、制定紀錄書寫規範、建置血液透析紀錄資訊系統、舉辦教育訓練、制定查核及實施獎勵辦法。實行改善措施後，血液透析紀錄不完整率由19.5%降至3.8%。本專案的實施，確實改善單位護理同仁血液透析紀錄完整率低之問題，提升病人安全及照護品質。

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.

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