月旦知識庫
 
  1. 熱門:
 
首頁 臺灣期刊   法律   公行政治   醫事相關   財經   社會學   教育   其他 大陸期刊   核心   重要期刊 DOI文章
長庚護理 本站僅提供期刊文獻檢索。
  【月旦知識庫】是否收錄該篇全文,敬請【登入】查詢為準。
最新【購點活動】


篇名
提升居家護理病歷書寫完整性之改善專案
並列篇名
The Project of Improving the Completeness of Home Care Nursing Records
作者 李康蘭胡彩蓮曹麗鳳黃素猜
中文摘要
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.
起訖頁 380-392
關鍵詞 居家護理病歷完整性nursing recordcompleteness
刊名 長庚護理  
期數 201809 (29:3期)
出版單位 財團法人長庚紀念醫院
該期刊-上一篇 利用無痛性保膚膜降低非預期性小兒靜脈重注射率之護理專案
該期刊-下一篇 縮短顏面骨折導航手術前準備時間之專案
 

新書閱讀



最新影音


優惠活動




讀者服務專線:+886-2-23756688 傳真:+886-2-23318496
地址:臺北市館前路28 號 7 樓 客服信箱
Copyright © 元照出版 All rights reserved. 版權所有,禁止轉貼節錄