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頁籤選單縮合
題 名 | 以品管圈手法提升血液透析護理紀錄之完整率=A Project to Improve the Integrity of Hemodialysis Nursing Record |
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作 者 | 蔡蕙鍾; 王春葉; 林耀信; 李建德; | 書刊名 | 病歷資訊管理期刊 |
卷 期 | 13:1 2014.07[民103.07] |
頁 次 | 頁19-34 |
分類號 | 419.26 |
關鍵詞 | 醫療品質; 血液透析; 護理紀錄; 品管圈; Medical quality; Hemodialysis; Nursing record; Quality control circle; |
語 文 | 中文(Chinese) |
中文摘要 | 透析病歷是透析治療過程中醫師之醫囑處置與用藥、護理照護過程及檢驗報告等紀錄,由醫療專業人員以電子化方式運作於HIS系統資料庫。血液透析護理紀錄的完整性可呈現整個醫療服務內容及成效,有利於醫療團隊的溝通,對病人病情進展、醫院評鑑、法律依據及教學研究影響甚鉅;所以血液透析護理紀錄必須完整、正確且詳細,因此我們成立專案以提升血液透析護理紀錄完整率。專案活動期間由2011年10月1日起至2012年3月31日止,旨在改善血液透析護理紀錄之完整性,進而提高血液透析的醫護品質。實施前查核300份透析病歷,發現護理紀錄之完整率僅達65.6%。經由專案小組以品管圈手法,討論現場作業流程,確立主要原因為:專業知識架構不足、缺乏資訊化交班紀錄規範、可參考標準紀錄範本不足、及列印前未檢視紀錄。接著針對特性要因擬定對策,執行方案有:安排在職教育訓練、公告並宣導透析交接班規範、建立資訊化紀錄標準範本供參閱、說明病歷紀錄查檢表、及實施獎懲制度。改善後,發現專案實施6個月後紀錄的完整率由65.6%提至92.8%,目標達成率為112.3%,進步率達41.7%。結案後,最近一次效果評估為2014年3月20日,稽核後發現紀錄完整率為96.7%,紀錄皆依作業標準書寫,且維持性佳。我們的結論認為透過專案活動可有效提升血液透析護理紀錄完整率。 |
英文摘要 | The dialysis medical record includes physician order, prescription, nursing care and laboratory ata. Currently it is operating with electronized recording by nephrologist and dialysis nurse in HIS system. It is conceivable that integrity of hemodialysis nursing record promises the completeness and efficacy of medical care during hemodialysis therapy. It also provides communication between medical team members, information of disease progression and also data base for hospital accreditation, legal issues and lastly dialysis medical record can offer important materials for medical education and research. It is therefore mandatory to enhance the integrity of hemodialysis nursing record. We conducted a project to improve the quality of the record. The project was conducted continuously for 6 months (Oct.1, 2011~Mar.31, 2012). Three hundred hemodialysis nursing records were reviewed prior to the project and the rate of completeness was 65.6%. We inspected operating procedures and identified four major factors contributing to inadequacy of nursing record: lack of professional education training; lack of guideline for shift reports; no hemodialysis record writing regulations and without preview before printing record. We then set up strategies to improve quality of record: to arrange professional educational training; to establish regulations and standard of record transfers; to formulate nursing record template as reference and to audit and monitor the quality of nursing record. We found that since this project has been undertaken for 6 months, the rate of completeness was increased from 65.6% to 92.8%, the goal achievement rate was 122.3% with improvement rate being 41.7%. The latest assessment was performed on 20, March, 2014 and we found the completeness rate was 96.7%. The writing was qualified and maintained consistently. It is concluded that our project has effectively improved the integrity of hemodialysis nursing record. |
本系統中英文摘要資訊取自各篇刊載內容。