以病人為中心的護理紀錄

Patient-centered Nursing Documentation

研究發現護理人員每日所執行的照護活動中，僅有40%會被紀錄於書面，且隨著護理活動增多，被登錄的越少。護理紀錄是護理人員照護病人的護理過程，亦是醫院評鑑的重要項目，本文介紹當代護理紀錄「以病人為中心」的概念來源，及其落實在實務過程中，應具備的撰寫要素，最後彙整文獻中有關影響護理紀錄品質的因素。期望護理主管在改善護理紀錄品質時，除透過稽核手法外，也能考量護理人員在撰寫過程中的影響因子，進行有意義的改善。

Previous study found that only 40% of provided nursing activities were recorded by nurses In addition, mote activities were provided, less were recorded. Nursing documentation was the record of patient care, and essential for hospital accreditation. The article introduced the idea of patient-centered record came from, and the essentials while applying the concept in practice. Finally, factors that affect nursing record quality were discussed. It is hoped that nursing managers should consider these affecting factors while conducting nursing record improvement project.