出院準備服務中心護理摘要單之改善－－以轉介至附設護理之家為例

An Improvement of Nursing Discharge Summary from Discharge-Planning Center to Nursing Home

照護需求訊息傳遞之完整性，是病患是否能獲得適當持續照護之影響因素。所以，一份完整的「護理摘要單」可以提供完善的照護評估內容，是出院準備服務成功的要素。護理之家是提供長期照護的主要型態之一，故本專案是以北部某醫學中心出院準備服務中心及其附設護理之家為例，進行實際訪談、觀察及問卷調查發現目前出院準備服務中心轉介至護理之家使用的「護理摘要單」因無法達到將病患的照護需求充分傳遞的目的，因此透過增訂表單填寫的操作型定義及修訂護理摘要單來改善。結果顯示不論出院準備服務中心或護理之家工作人員在「護理摘要單」是否可以完整評估護理照護問題方面對表單修改前後比較有達統計顯著意義(p＜.05)；護理之家工作人員對於「護理摘要單」是否可以完整提供照護住民指引方面對表單修改前後比較有達顯統計顯著意義(p＜.05)。本專案所修訂之「護理摘要單」可應用在出院病患需要長期照護時之參考。

The appropriate and systematic communication between one medical center and related unit is a key factor of helping individual inpatient safely getting continuative care after discharged. Therefore, a complete Nursing Discharge Summary Sheet which can provide integral contents of assessment and nursing care is a key to success in discharge planning. Nursing home is one of the main types of institutional model of long-term care. We found that the nursing summary sheet could not be used completely on patient need while patient is being discharged from hospital and transferred to the nursing home. It could be improved by extra sheets that have been revised and been clearly defined. In this project, the data were collected by interviewing, observation, and questionnaire survey. This projected was conducted at the discharge-planning center and nursing home at a hospital in northern Taiwan. The result showed that the evaluation of nursing care was significant improved by using the revised nursing discharge summary sheet. The result also showed that completeness of nursing care guidance was improved. It indicated that the revised nursing discharge summary sheet could be used in discharged patients who need subsequent long-term cares.