提昇急診護理人員正確記帳專案

A Project to Improve Charting Accuracy among Emergency Nurses

據某院方資料顯示急診部的財務每月呈虧損狀態，而急診部每月被院內健保預審小組查獲約4至5件因護理人員記帳不正確造成的損失。故本專案乃探討急診護理人員記帳不正確的原因，並擬定改善方案，以提高記帳正確率至90%。本專案採調查法，以記帳單為對象，使用查檢表於急診暫留區進行資料收集；資料結果以百分比及卡方檢定進行分析。結果顯示：影響記帳不正確的原因為護理人員對於正確記帳的認知不足、急診忙碌急迫的工作特性、記帳單設計不良、政策上的缺失。經過專案計畫實施後，同樣是收集六天200係的記帳資料，記帳正確率由77.92%提高至89.73%元降低至9.848元，護理人員對於正確記帳的方式、健保給付的規定記帳項目的內容及成本概念，均有所增進。若持續進行專案計畫，預期會有更好的成效。

According to the financial reports of National Taiwan University hospital, the emergency department had suffered a negative financial balance for many months. Part of the negative financial balance was due to incorrect charting. It was known that there was an average of four to five incorrect charting cases every month in our emergency department. The purpose of this project was to explore the causes of incorrect charting, and plans were proposed to improve the correct charting ratio to 90%. The data were collected from the charting sheets filled in by nurses working in the observation section of the emergency department. In this project, percentages and the Chi square test were used to analyze the collected data. After intervention, the results showed that mistakes were caused by the lack of correct knowledge about charting, work overload of nurses, poor design of the charting sheet, and inconsistent policies. After a systematic training program, the correct charting ratio was increased from 77.92% to 89.73%, and the financial loss was reduced from NT$28,877 to NT$9,848. Nurses also became more familiar with the charting system, the regulations of the National Health Insurance, the understanding of each charge item, and the important of cost awareness. Better results can be expected by continuing implementation of the training program.