提升恢復室護理人員執行護理記錄書寫完整性之改善專案

A Project to Improve the Completeness of Nursing Record in Post-Anesthesia Care Unit

彭沛語(Pei-Yu Peng)；鄭秋子(Chiu-Tzu Cheng)；李映春(Ying-Chun Lee)；石惠美(Whei-Mei Shih)；李夢英(Mung-Yeng Li)；吳寶媛(Pao-Yuan Wu)

完整性 ； 護理記錄 ； 恢復室 ； completeness ； nursing record ； post-anesthesia care unit

志為護理-慈濟護理雜誌

17卷5期（2018 / 10 / 01）

101 - 112

繁體中文

護理記錄是病人接受醫療照護完整而有系統的記錄，清楚明確的記錄將有助於醫療團隊維持照護連續性。臨床中發現人員執行術後恢復護理記錄不完整包含：意識、身體評估及疼痛評估、PAR Score（post anesthesia recoveryroom score）等，影響照護品質與連續性。自2013年3月1日至9月30日透過專案有效策略的實施：籌劃護理資訊系統介面、修訂護理記錄書寫準則等措施、成立諮詢人力庫及規劃護理記錄書寫在職教育等對策。結果顯示護理記錄書寫完整性由86.6%提升至96％，達專案目標進而提升術後照護連續性與照護品質。

Nursing record is a complete and systemic documentation of the medical care patient receives. A clear and concise nursing record can provide medical teams the necessary tool in maintaining continuity of care. In this project, we discovered in a clinical setting the incompleteness of post anesthesia care records on items including coma scale, physical assessment, pain assessment, PAR Score(Post Anesthesia Recovery room Score), which affected the quality and continuity of care. From March 1^(st) to Sept. 30^(th), 2013, the following measures were implemented: planning a nursing information system interface, revising nursing record standard, setting up a consultation team, and plan continuing education on nursing record. The results revealed an improvement on the completeness of nursing record from 86.6% to 96%, reaching the intended goal of this project, and enhanced the continuity and quality of postoperative nursing care.

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