精神科日間病房藥物管理紀錄方式改善方案

Project to Improve Medication Regulation and Management Records in a Psychiatric Day Ward

10.6847/TJPMHN.200906_4(1).0005

陸瑞玲(Ray-Ling Luh)；林明熙(Ming-Shi Lin)；張阿雪(A-Sheu Chang)

精神科日間病房 ； 藥物管理 ； psychiatric day ward ； medication management

精神衛生護理雜誌

4卷1期（2009 / 06 / 01）

39 - 46

繁體中文

本專案目的為提升日間病房藥物管理紀錄方式完整率。在慢性精神病治療過程中，依醫囑規律服藥是避免疾病復發重要因素之一。本單位查核藥物管理相關紀錄未達護理紀錄技術稽核80%之閾值。分析問題原因為：1.缺乏專屬精神科日間病房『藥物管理紀錄單』；2.交班單未完全標示所有個案之藥物訓練方式。專案小組經由決策矩陣分析法提出解決方法有：1.制訂『藥物管理紀錄單』；2.在院服藥個案使用護理部制訂使用之『藥物治療紀錄單』；3.加強各項護理紀錄及交班單之查核，結果：1.藥物管理紀錄方式完整率達100%；2.護理紀錄呈現藥物管理紀錄達93.2%，顯示本專案具有提升藥物管理紀錄完整性及服務品質之效益。

The purpose of this project was to improve the integrity levels of medication regulation and management records in a day ward. In the treatment of chronic mental illness, regular medication adherence is important to the prevention of recurrence of illness. The organization's checking of medication management records was yet to exceed the 80% nursing skills audit threshold. The reasons for this were: 1. Lack of a specialist medication management record sheet for a psychiatric day ward. 2. Nursing shift sheets did not fully indicate the methods used to train patients in medication compliance. The solutions provided by the project team, by means of the policy-making matrix analytic method, were: 1. The establishment of the Medication Management Record Sheet. 2. Day ward patient compliance, in the taking of medication, with a Medication Administration Record designed by the department of nursing. 3. Enhancement of the checking of nursing records and nursing shift sheets. The results showed that: 1. The integrity rate for medication management record keeping increased to 100%; 2. Medication management records began to account for 93.2% of nursing records, demonstrating that this project achieved the benefits of promoting both medication management record integrity and service quality.