骨科病房護理紀錄書寫之改善方案

A Performance Improvement Project for Orthopendic Nursing Documentation

護理紀錄是提供醫療服務重要資料，必須力求完整、正確，呈現各專科疾病特色。某骨科病房護理人員常因護理紀錄內容多且重覆感到困擾。本專案目的為改善病房護理紀錄及增加護理人員對記錄之滿意度，筆者於2007年3月期間收集結果發現護理紀錄的現況為：1.紀錄內容重覆性高及缺乏完整性。2.表單繁複，紀錄書寫耗時。3.”紀錄書寫準則”缺乏專科性。4.人員對紀錄書寫滿意度平均為2.79分。經修訂護理紀錄準則，簡化及重新設計表單，與格式化骨科護理紀錄，其結果顯示1.紀錄完整性達96%。2.紀錄書寫時間平均每個案為237.19秒，每個案較改善前節省279.03秒。3.護理紀錄書寫之滿意度提昇為4.19分。改善結果無論在內容完整性、護理人員滿意度或書寫時間方面皆有顯著成效，可做為未來其他科別臨床護理紀錄改善參考。

Nursing documentation is an important part of medical records and must be accurate, complete, and diagnosis-specific. Nursing staff in an orthopedic unit is often confused by duplicate nursing charting. This project aimed to improve nursing documentation in an orthopedic unit and to increase nurse satisfaction in charting thereafter. Data were collected in March 2007. Several problems were identified: (1) contents of nursing records were duplicated and incomplete; (2) nursing documentation forms were complicated and time-consuming to complete; (3) the 'principle of nursing documentation' was generalized and lacked diagnosis-specific details; (4) the score of nurse satisfaction on nursing charting was 2.79 out of 5. The principle of nursing documentation was redefined. The contents of nursing records were redesigned, reformatted, and simplified. The post survey indicated improvement in nursing charting as follows: (1) completeness of chart contents raised to 96%; (2) time spent on nursing documentation was reduced from 279.03 sec/case to 237.19 sec/case; (3) nurse satisfaction was 4.19, much higher than the previous score. The research showed obvious improvement in the contents of nursing charting, time spent on charting, and nurse satisfaction on charting. The research method can be applied in other units where colleagues would like to improve nursing documentation.