腫瘤護理紀錄書寫時間縮短方案

Reducing the Amount of Time Spent in Writing the Oncology Nursing Records

護理人員紀錄之書寫，包含護理紀錄與交班單，本單位由於交班單內容項目繁多，且與護理紀錄重覆性高，使得護理人員花費頗多時間書寫紀錄，屢有怨言。本專案小組藉由建立腫瘤科交班之標準作業程序及改變交班單內容，並設計「制式化焦點問題小單張」合併護理紀錄交班，以縮短護理人員書寫紀錄的時間。專案實施十個月後，「制式化焦點問題小單張」與護理紀錄重覆性由90％降低至43％，書寫紀錄的平均時間亦由56.3分鐘降低至39分鐘，較實施前縮短17.3分鐘，直接增加臨床照護病人的時間；而落實交班之標準作業程序，更符合醫策會推動病人安全的目標與策略，期盼將來可推行至其他腫瘤科病房。

The content of nursing records is posted on a nursing record sheet and shift report sheet in the oncology ward.The shift report sheet content is highly repetitive information in the nursing record sheet.The object of this project is to establish the standard procedure of shift reports in oncology ward by changing the content of report sheets, and designing a new format called ”Format focus problem list sheet.”After ten months of this project using this new procedure, the percentage of repetition work in the ”Format focus problem list sheet”between the nursing record sheets decreased from 90% to 43% . The amount of time spent writing in nursing records also decreased from 56.3 minutes to 39 minutes.This project has reduced 17.3 minutes in writing time as compared to the previous procedure. Furthermore, the 17.3 minutes can be used in clinical care for patients. In other words, performing the standard shift report procedure is in accordance with the goal and strategy of patient safety in Taiwan Joint Commission on Hospital Accreditation. We hope this project can be widely used in other oncology wards in the near future.