加護單位導入焦點護理記錄系統對護理人員於臨床個案執行護理計劃之成效

The effectiveness of application the focus charting system in clinical nursing care plan

高品質的護理記錄內容除為病人照護及品質監測基礎外，亦是醫護人員與病人間溝通工具，適當的記錄護理照護過程實為重要。本研究旨在探討焦點護理記錄系統導入後，護理人員於臨床執行護理計劃成效，並進行相關影響因素探討；研究有效樣本為某醫學中心150位加護單位護理人員，以結構性問卷進行調查及回溯系統資料，研究結果顯示：(1) 護理人員對焦點護理記錄系統導入標準化焦點護理記錄滿意度，平均得分為3.68±.595，約66.6%達滿意程度；(2) 內科加護病房、有接受教育訓練及自行閱讀資料的護理人員，滿意度明顯較高；(3) 不同年齡、總護理工作年資、單位護理工作年資、任職型態及能力進階層級之護理人員對標準化焦點護理記錄滿意度並無明顯差異；(4) 有78%護理人員認為可減少其書寫護理紀錄時間；(5) 對於執行病人護理活動的獨特性，僅約48%護理人員感到滿意；6)護理評估、護理措施及評值方面的記錄完整性介於83~95%，護理指導記錄完整性則僅約15~30%，且導入焦點護理紀錄系統後，護理計劃書寫的成效達顯著差異。最後建議，機構應更加重視護理人員對於系統使用的看法、經驗及其滿意度，以利記錄系統持續發展，降低工作負荷。

Background: Nursing documentation is an important issue for nursing. Good practice in record keeping can help to protect the patients by high quality and continuity of care and effective communication. Purpose: To investigate the nurses’ opinions about using clinical nursing care plan in the focus charting system and quality for clinical practice. Methods: This survey design was used to sample participants of intensive care unit nurses in the medical center. A structured questionnaire was used to collect data and total of 150 valid questionnaires were collected. And the other, a retrospective research design with a quantitative approach was applied to assess the status of nursing documentation of patients who were admitted to the seven ICU in the first 72 hours of admission, including clinical nursing care plan with pressure ulcer, endo-tracheal intubation painful, ineffective airway clearance, impaired cardiopulmonary perfusion, and high risk of infection recording. Results: (1) The nurses’ perceptions of the using clinical nursing care plan in the focus charting system scored average of 3.68±.595; (2) The majority of the nurses were of the opinion that using nursing care plan increase their ability to provide the same quality basic care for all patients; (3) Most agreed (78%)the application the focus charting system in clinical nursing care plan decrease documentation time; (4) Completeness of documentation was 83% to 95% for nursing assessment, intervention and evaluation. Use of the focus charting system can improve nursing documentation. Conclusions: The results showed that provided education programs is needed to teach nurses how to using nursing care plan in the focus charting system.