整合護理資訊系統建立提升血液透析記錄之完整性

Use Nursing Information System to improve the Completeness Rate of the Hemodialysis Nursing Records

背景：透析護理紀錄的完整性有利於醫療團隊的溝通及維持病人照護品質。由2017年1月2日至1月15日因表單書寫欄位過多導致書寫不完整，完整率僅為87.6%；因同時照護不同身份透析病人，文書、系統作業花費工時為54-55.5分鐘佔了一半以上護理工時，且病人無法獲得良好的照顧，人員工作滿意度為3.5分，故引發改善此案動機。

目的：本專案旨整合護理資訊系統，提升血液透析記錄之完整性。

解決方案：建立透析護理資訊系統介面操作達統一入口、急住診透析治療區分區、增加電腦硬體配置、整合護理記錄表單等策略實施。

結果：專案結束後，紀錄完整率提升至95.3%、文書所花費工時縮短為9.8-11.3分鐘、工作滿意度達4分。

結論：本專案實施結果，可有效提升血液透析記錄之完整性，以維護病人安全並提升照護品質。

 

Background & Problems: The integrity of the Dialysis Care Records is conductive to the communication between the medical teams and the maintenance quality of the patient care. From January 2 to January 15, 2017, since too many writing fields related incomplete nursing records, these all resulted in a record integrity rate of only 87.6% .Due to caring for dialysis patients of different identities at the same time, 54-55.5 minutes of paperwork and system work accounted for more than half of the nursing work hours, and patients could not get good care, the nurse job satisfaction score 3.5 on a 5-point scale. There for, the motivation for setting up a task force was launched.

Purpose: This project aimed to improve the integrity of hemodialysis records by using a nursing information system.

Resolution: We established a unified portal for operating dialysis care information system, divided different treatment area for emergent, in-hospital, and outpatient hemodialysis, increased computer hardware configuration, and integrated the nursing record sheet.

Results: After the project ended, the record completion rate increased to 95.3%, the paperwork time was shortened hours to 9.8-11.3 mins, and the job satisfaction score reached to 4 point.

Conclusion: The results of this project can effectively integrate the hemodialysis records, maintain the patient safety and improve the quality of care.