簡化成癮防治科病房護理記錄書寫專案

The Project of Simplifying Nursing Records in Wards of Addition

本專案旨在簡化成癮防治科病房護理記錄之書寫，期望藉由本專案的執行，縮短護理記錄之書寫及增加直接照護病患之時間和病患滿意度。筆者發現護理人員忙於書寫記錄、經常延遲下班，病患也因無法被及時處理問題而有所不滿，經分析發現是成癮防治科護理記錄書寫種類繁瑣且量多、護理記錄單張重疊性高，及護理人員組織能力不足等因素造成。故設計了符合以問題為導向之勾選式記錄單張共九種，簡化及整合重疊性高之護理記錄及安排在職教育等，結果顯示：護理記錄之書寫時間白班每人由215分鐘縮短至87分鐘，夜班由180分鐘縮短至50分鐘，病人對護理人員直接照護時間之滿意度由40%提高至82.5%，顯示專案之實施可節省時間並提昇護理品質。The purpose of this project was to reduce writing work of nursing records and increase satisfaction of patients and nurses through simplifying nursing records in the ward of addition. The author found nurses always busy in writing several kinds of records that usually led to delay their off duty and caused patients' complaints for unsolving their problems timely. The reasons included that the records were numerous and miscellaneous, with many being highly overlapping, and the organization ability of nurses were limited. Our team designed three strategies as follows: developing nine problem-oriented optional recording sheets, simplifying and combining the highly overlapping sheets and arranging continuous education. The result showed: writing time of nursing records in day shift per nurse was shortened from 215 minutes to 87 minutes and in night shift shortened from 180 minutes to 50 minutes; patients’satisfaction increased from 40% to 82.5% and nurses’ satisfaction increased from 0% to 100%, indicating that the project was effective in reducing time consuming and enhancing the quality of care.