提升某內科病房護理記錄完整率之方案

Improve Nursing Documentation in a Medical Unit

10.6530/YYN.2010.4(2).06

顧文卿(Wen-Ching Ku)；陳美蓉(Mei-Jung Chen)；白玉珠(Yu-Chu Pai)

護理記錄 ； 健康問題 ； 護理診斷 ； nursing documentation ； health problem ； nursing diagnosis

源遠護理

4卷2期（2010 / 11 / 01）

42 - 49

繁體中文

本單位之護理記錄常有一些遺漏及錯誤且內容過於簡化，經稽核發現其完整率為64.1%，故極待改善。經現況分析發現：護理人員欠缺護理記錄所需專業知識、缺乏臨床記錄實際指導、不瞭解記錄應具備的內容，及未認知記錄完整性之重要等問題。綜合以上缺失，自2007年4-12月進行改善方案，提出策略為教育訓練、提供臨床記錄個別指導及制訂書寫範例等，經執行後整體完整率提升為90.5%。雖已達成目標，但需更加努力，因本單位為某醫學中心之綜合內科病房，病人疾病嚴重度及複雜性較高，故應加強相關護理知識之充實，身體評估訓練等。建議未來可製定專科各項常見且具獨特性之健康問題範例；且於在職教育訓練中提出記錄之分析及討論，以提升護理記錄之完整性。

Nursing documentation was one of the areas requiring improvement in a high acuity medical unit in a metropolitan teaching hospital. Chart reviews showed that only 64.1% met the requirements in nursing documentation. The rest of the documentations were incomplete, incorrect or superficial. Reasons for low competency in documentation included lack of professional knowledge, improper clinical orientation, and not understanding negative consequences of poor documentation. This study resulted in a 9-month documentation improvement project in 2007. The educational program included didactic sessions, individual coaching, and setup templates for documentation. The rate of compliance increased to 90.5% after the training. The project continues to raise the bar on nursing knowledge and physical assessment skills on complicated diagnosis and nursing problems.