建置某安寧病房護理資訊系統之專案

Development of an Electronic Nursing Record System in a Hospice Palliative Care Ward

10.6537/TJHPC.201912_23(3).05

陳雅伶(Ya-Ling Chen)；陳琬喬(Wan-Chiao Chen)；蔡守婷(Shou-Ting Tsai)；張詩吟(Shih-Yin Chang)

護理資訊系統 ； 安寧護理紀錄 ； electronic nursing record system ； hospice palliative care

安寧療護雜誌

23卷3期（2019 / 12 / 01）

267 - 279

繁體中文

研究目的：資訊化護理紀錄較紙本紀錄更能進行訊息傳遞，經調查發現紙本護理紀錄使用者滿意度僅33.3%，故成立專案小組。研究方法：經分析發現主要問題為：紙本紀錄無法修改導致畫面雜亂、單張種類多，不符合書寫記錄需求；交接班時需逐頁翻閱各項紀錄，易遺漏照護訊息。結果：經執行專案對策，建置安寧護理紀錄資訊系統與擬定「安寧護理紀錄」系統功能、整合紀錄單張，規劃「生理問題護理紀錄表」的格式、增設護理資訊紀錄連結功能、執行護理紀錄資訊系統使用者在職教育後，單位護理人員對護理紀錄撰寫滿意度提升至95.8%。結論：建置安寧護理資訊紀錄後能整合紀錄單張，運用護理紀錄資訊系統能讓紀錄內容清楚且一目了然；交接班時也不會遺漏重要照護訊息，符合護理人員撰寫紀錄與交接班需求，有效提升使用者滿意度及工作效益。

Background: The electronic nursing record is a lot more capable of sending information than the handwritten record. After conducting an investigation, we found that user's satisfaction of the handwritten record was only 33.3%. Methods: Through some analysis, the main problem were found that the handwitten record could not be modified, resulting in messy pages, various kinds of single record sheets were not integrated for the staff to write the records easily. Moreover, after a handover was completed, all the records had to be read page by page, and it was easy to miss some caring document. Results: The following are implementing countermeasures: establishing the electronic nursing record system, integrating each single record sheet, planning the ＂Physical Problem Nursing Record Form＂ format, adding the function of the Nursing Information Record Link and performing in-survice education for users. Finally, the overall user satisfaction increased to 95.8%. Conclusions: After the electronic nursing record system was set up, the records in each single sheet could be integrated. Using the electronic nursing record system made the records clear and the staff understood them fully at one glance. The important care messages wouldn't be missed during the nurse-to-nurse handover. It also increased the user's satisfaction and work efficiency effectively.

1. 李作英(2017)。資訊科技決策中護理資訊人員之角色功能。護理雜誌，64(4)，5-9。
   連結：
2. Beach, J,Oates, J(2014).Maintaining best practice in record-keeping and documentation.Nurs Stand,28(36),45-50.
3. Kallen, MA,Yang, D,Haas, N(2012).A technical solution to improving palliative and hospice care.Support Care Cancer,20(1),167-174.
4. Kelley, TF,Brandon, DH,Docherty, SL(2011).Electronic nursing documentation as a strategy to improve quality of patient care.J Nurs Scholarsh,43(2),154-162.
5. 于湘梅,徐嫈月,施叔杏,莊馥蓮,曾昭梅,張淑芳(2014)。兒科電子化護理紀錄之改善方案。榮總護理，31(1)，83-92。
6. 王曼蒂,楊淑慧,宋佳穎,劉淑芳,陳碧蓮(2011)。影響護理人員使用護理紀錄標準化範本之相關因素。榮總護理，28(3)，241-248。
7. 林政杰,黃明國,賴偉民,黃梅芬,林佳靜,盧蔚駿(2013)。綠色雲端應用架構之發展與應用：以醫院雲端護理爲例。醫院雙月刊，46(4)，9-22。
8. 林慧君,陳俞君,林琪馨(2013)。提升加護病房電子病歷護理交班之完整性。志爲護理，12(1)，77-87。
9. 侯宜菁,游惠珠,陳建民,吳榮軒,藍敏芳,黃月嬌(2010)。護理評估資訊系統使用前後對護理紀錄時間及紀錄品質成效之探討。源遠護理，4(1)，11-20。
10. 張翠容,涂明香,張柏論(2010)。護理人員自建護理紀錄系統之初探：以 Kardex 爲例。榮總護理，4(1)，21-30。
11. 黃品甄,盧小玨,張博論(2011)。護理紀錄語料及辭典建置之研究與應用於語音辨識之可行性評估。醫療資訊雜誌，20(2)，25-35。
12. 黃惠玲,張元玫,歐李美智,湯慎元,李亭亭(2011)。資訊科技在護理應用─應用決策支援系統於門診護理指導資訊系統。護理雜誌，58(1)，79-84。
13. 趙可式,李慧菁(2007).安寧療護紀錄表單填寫說明與範本.臺北:台灣安寧緩和護理學會.
14. 劉梅英,劉雪娥,王宏銘(2014)。癌末安寧共同照護監測紀錄表的設計。志爲護理，13(3)，66-81。

1. 羅心怡,鄭青青,柯秀惠,林秋子,吳孟慈,毛亮月(2023)。提升高壓氧治療作業完整性。長庚護理，34(3)，46-59。