提升外科專科護理師病歷紀錄正確性之改善專案

Improving the Accuracy of Medical Records: A Project forSurgical Nurse Practitioners

背景：病歷紀錄不正確影響病人安全與醫院醫療照護品質。經審查30位外科專科護理師病歷紀錄正確性僅平均86.6分，43.3%個人達90分以上。藉問卷、觀察與訪談分析病歷紀錄不正確要因為：英文書寫表達有困難，疾病評估及照護知識的限制，電子病歷書寫系統使用不易，教育訓練不足，書寫範本種類不足，缺乏審查機制。

目的：專案目標為提升專師病歷紀錄正確性達平均90分以上；個人正確性能達90分的比率達88.7%以上。

解決方案：2017 年9月至2018 年4月透過建置多元化雲端資料庫、推廣數位教材、舉辦面授課程、問題導向病歷寫作小組教學、制定審查與獎勵辦法。

結果評值：病歷紀錄正確性平均95.9 分，個人得分達90分以上者共96.7%，達成專案目標。

結論：多元教學策略與數位教材資料庫之可平行推展到內科專科護理師，後續納為新進人員訓練內容。

 

Background & Problems: Medical record inaccuracy affects not only the safety of patients but also the quality of medical care in hospitals. The audit revealed the accuracy of the medical records of 30 surgical nurse practitioners was low (average score was 86.6, and only 43.3% of individuals scored 90 and above). Difficulties in writing and ex-pressing in English, limitations of disease assessment and health care knowledge, the non-friendly electronic medical record system, insufficient education and training, deficiency in writing templates, and lack of audit mechanisms were the factors caused medical record inaccuracies. These factors were revealed by the questionnaire, observations, and interviews.

Purpose: The project aimed to improve medical records accuracy to at least average 90 points, and ensure 88.7% of individuals score 90 points and above.

Strategies Procedures: From September 2017 to April 2018, strategies including establishment of a diverse cloud database, promotion of digital teaching materials, holding face-to-face courses and problem-oriented medical record writing group courses, and setting audit and reward rules were implemented.

Outcome Evaluation: Results revealed that the average accuracy of the medical record was 95.9 points, and 96.7% of individuals scored 90 points and above. The aims of the project were achieved.

Conclusions: The multiple teaching strategies of this project and the digital teaching materials database could be ex-tended to the internal medicine nurse practitioners and be included in training course for novice nurse practitioners.