提升居家護理病歷書寫完整性之改善專案

The Project of Improving the Completeness of Home Care Nursing Records

病歷書寫不完整，影響個案連續性照護、甚至健保費用核刪。本專案目的於提升居家護理書寫病歷完整性。本單位居家護理病歷書寫完整性僅為78.94%，發現問題為：（1）紀錄單多；（2）同仁不清楚病歷書寫規範；（3）書寫記錄時段被中斷、增加臨時業務、單張書寫頻率不一致。解決辦法為：（1）舉辦居家護理病歷書寫共識會議並整合病歷單張；（2）居家護理病歷資訊化；（3）修訂居家護理病歷完整性管理及審核作業辦法；（4）製作病歷紀錄範本成冊；（5）彈性增加紀錄班別。結果：居家護理病歷書寫完整性提升至96.41%，達成專案目標。建議可應用到其他家護理機構提供日後改善或推動電子病歷系統時之參考。 Writing nursing record incompletely may have impact on the continuity of nursing care and eventhe reduction of insurance payment. The aim of this project is to improve the completeness of home carenursing records. The completeness of nursing home care records was 78.94%, and the inadequacy ofnursing records related to: 1) Too many record formats. 2) Nurses were not familiar with the written norm.3) Nurses were interrupted by temporary tasks while writing record. The methods were to: 1) organize anursing record writing consensus meeting and integrate record sheets, 2) computerize nursing records, 3)revise the management and auditing methods for the integrity of nursing home care records, 4) bind upthe records sample and file them, and 5) flexibly increase record writing shift. Results showed that thecompleteness of home care nursing records rose to 96.41%. The improvement project may be useful in theother similar institutions. The results can serve as a reference when the nurse home care institutions are topromote the use of an electronic medical record system.