產科病房護理記錄改善專案

Improving Efficiency of Postpartum Nursing Records at a Obstetric Ward

護理記錄是提供醫療服務的重要資料，因此必須力求完整、正確與具個別性，呈現各專科疾病特色。在北部某教學中心中，產科病房人員經常因工作量大以及護理記錄內容多重覆且費時而感到困擾。是故本專案目的在於改善產科病房產後護理記錄，於87年4月23日至87年6月23日期間，利用實際觀察及訪談法收集現況產後護理記錄執行情形，結果1.護理記錄版面凌亂、內容大同小異、缺乏完整性、重複性高；2.書寫記錄耗時。因此參考文獻及現況收集結果，建立涵括產婦生、心層面的『產後格式化護理記錄標準』記錄方式。透過宣導、人員在職教育、試行及再修正後，在產科病房全面推行，其結果顯示1.提高記錄完整性達100%，較執行前增加55.4%；2.平均書寫記錄時間為60秒／每個案，較改善前降低110秒／每個案。其中自然生產轉入時記錄為55秒／每個案，較改善前降低125秒／每個案，剖腹生產轉入時記錄為80秒／每個案，較改善前降低150秒／每個案，每日病程進展記錄方面為45秒／每個案，較改善前降低55秒／每個案；3.人員滿意度方面88.6%護理人員表示產後格式化護理記錄標準對記錄完整性有幫助的，對記錄方式改變持正向看法。藉由記錄方式改善的推行結果在內容完整性、書寫時間及人員滿意程度方面確實有顯著的成效，可作為臨床護理記錄改善的參考。

The nursing record is an important medical document and should be comprehensive, accurate, and individualized. In a medical center located in northern Taiwan, nurses have been burdened by redundant postpartum recording in addition to the heavy load of clinical work. The aim of this project was to improve the quality and efficiency of postpartum nursing records on an obstetric ward. The study period was from April 23,1998 to June 23,1998. Data were collected using on-site observation and interviews with nurses regarding the current postpartum nursing record. Results revealed that the inadequacy of nursing records related to: 1) poor format and use of clich's, 2) incompleteness or repetition of content, and 3) time required to complete the record. A literature review and evaluation of the current situation were done to develop a 'standardized postpartum format of nursing record' (SPFNR). The SPFNR included physical and psychological care of parturient women. After thorough promotion of the SPFNR, education of nurses, and several revisions, the SPFNR was used on an obstetric ward. Results showed an increase of 55.4% completeness compared with previous nursing records. The average time to complete one nursing record was 60 seconds - a reduction of 110 seconds compared with the previous method. Recording time was further factored as follows: 55 seconds per record for normal spontaneous deliveries which saved 125 seconds, 80 seconds per record for cesarean section deliveries which saved 150 seconds, and 45 seconds per record for daily progress notes which saved 55 seconds. Moreover, 88.6% of nurses felt positive about the SPFNR and thought it improved the accuracy of nursing records. Findings can be used in the clinical setting to improve the comprehensiveness of nursing records, save recording time, and increase nurse satisfaction.