頁籤選單縮合
題名 | 提昇護理紀錄書寫完整性之改善方案=The Project of Promoting Nursing Records Completeness |
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作者 | 常玉琴; 黃惠姿; 王襄華; 張雅惠; 樊君儀; 高麗娟; 戴千淑; Chrang, Yuh-chirn; Huang, Huei-tzu; Wang, Hsiang-hua; Chang, Ya-huei; Fan, Chun-i; Kao, Li-chuan; Tai, Chien-shu; |
期刊 | 榮總護理 |
出版日期 | 20090900 |
卷期 | 26:3 2009.09[民98.09] |
頁次 | 頁304-310 |
分類號 | 419.9 |
語文 | chi |
關鍵詞 | 護理紀錄; 護理專案; 書寫完整性; Nursing records; Nursing project; Records completeness; |
中文摘要 | 完整的護理紀錄是病人安全及照護品質的基本要素。本專案目的為提昇護理紀錄書寫完整性。某醫學中心督導長單位中層品管組查核護理紀錄書寫完整率僅有68.2%,未達閾值,經現況分析後確立原因為:未及時書寫、筆誤、對護理紀錄書寫方式認知不一致、未及時掌握相關規定、制式化書寫致欠缺個別性等因素。針對以上原因提出解決對策有:製作護理紀錄查檢表、貼提醒標語、留言提醒更改、加強宣導、制定參考範例、成立諮詢人才庫、建立訊息傳遞網、舉辦在職教育、每週稽核、配合個別輔導及情境討論等方法。實施四個月後護理紀錄書寫完整率已提高至82.7%,目標達成率122.9%,進步率21.3%,本專案為督導長單位跨科及跨組別共同攜手合作,有效提昇護理紀錄完整性。 |
英文摘要 | Good quality records are essential to safe and effective patient care. The objective of this project was to improve nursing record completeness. Our statistical result showed only 68.2% lower than the threshold of nursing records were complete. The problems were: not documenting immediately, a lapse of the pen, lack of and not catching on standardizing methods and individuality. Discussed solutions were: setting up checklists, reminders, standardized forms, inquiry center, message relay networks, enhancing instructions, weekly audit and holding lectures. After implementation, the completeness was increased to 82.7%. The goal achieved rate was 122.9% with improvement rate being 21.3%. This project was collaborated with assistance and showed effective improvement to nursing record completeness |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。