減輕安寧共照護理師書寫病程紀錄負擔之多元策略

Multiple Strategies to Reduce Burden of the Progress Note Writing among Hospice Shared-Care Nurses

安寧緩和共同照護紀錄撰寫耗時，且具挑戰性。調查顯示，新案與複雜個案書寫超過60分鐘佔71.4%和85.7%，舊案集中在30-60分鐘（100%）。書寫困擾程度達嚴重（含）以上佔71.4%。主要問題包括缺乏書寫規範、可供參考的範本，及團隊共識。為改善此情形，團隊運用多元策略：透過世界咖啡館凝聚共識、制定書寫作業規範、發展半結構紀錄模板、建置生命末期照護資料庫等。由全院7位安寧共照護理師實際應用與評值。介入後，新案書寫>60分鐘降至0%，舊案>30分鐘和複雜個案>60分鐘均降至28.6%，困擾程度為嚴重（含）以上者降為0%；同時工作滿意度由1.57分提升至2.43分。多元策略可有效降低書寫負擔，並提升工作滿意度。將持續追蹤成效，並結合資訊系統優化書寫流程，以提升整體照護品質。

The hospice shared care record keeping takes significant time and presents challenges. A survey revealed that the proportion of new cases and complex cases taking more than 60 minutes for progress note writing were 71.4% and 85.7%, respectively, while follow-up cases were completed within 30-60 minutes (100%). Additionally, 71.4% of nurses reported experiencing severe to very severe levels of distress during documentation. The main problems included the lack of standardization guidelines, templates, and team consensus. To address these challenges, a multi-strategy intervention was implemented, which included utilizing the World Caféstrategy to develop standardized documentation guidelines, create a semi-structured format, and establish an end-of-life care database. Seven hospice care nurses participated and evaluated the effectiveness of the intervention. After implementation, for new cases, 0% exceeded 60 minutes, while for follow-up cases and complex cases, the proportion exceeding 30 minutes and 60 minutes, respectively, decreased to 28.6%. Furthermore, the proportion of nurses reporting severe to very severe distress reduced to 0%. Job satisfaction increased from 1.57 to 2.43. The multi-strategy approach significantly reduced the documentation burden and enhanced job satisfaction. Continued monitoring and integration with information systems are planned to further optimize the documentation process and improve the quality of nursing care.