中醫住院護理病歷標準化之研究

THE STUDY OF NURSING RECORD STANDARDIZATION IN TRADITIONAL CHINESE MEDICINE OF INPATIENT CARE

本研究目的係為建構中醫住院辨證評估施護後之入院護理病歷紀錄及護理病歷書寫指引標準，並針對設立中醫護理標準後臨床中醫護理人員執行的成效進行相關探討，藉以提升我國中醫護理照護的品質與提昇中醫護理人員的專業能力。先收集國內外及過去中醫護理記錄及護理計畫的內容與標準，以專家會議德菲法（Delphi Method）進行專家內容效度針對「中醫護理病歷記錄」之內容及指引標準進行專家意見修正。研究結果顯示，經專家效度鑑定後，依專家的意見結果求取內容效度指數（Content Validity Index, CVI），皆達到0.8。完整的中醫住院護理病歷內容應涵蓋：（1）病人基本資料、家族史、四診辨證評估資料、理學檢查、施護內容及評值。（2）一般性的辨證施護記錄：包含西醫一般檢查、生命徵象（體溫、脈搏、呼吸、血壓），運用中醫望、聞、問、切的四診評估記錄病人的脈象、舌苔、神志、汗、嘔吐、二便，患者現存的中醫健康護理問題、記錄醫囑中涉及的護理問題、對患者告知內容的記錄以及重要環節中護理問題的記錄。（3）病重患者護理記錄：除應有一般性的護理記錄外，更應詳細記錄病情的變化過程經過及採取的具體措施。研究發現，護理人員的中醫護理專業知識與照護能力會影響其紀錄執行之品質，建議中醫病房護理人員應接受中醫基礎護理七科目九學分的訓練並通過能力認證，以確保病患照護品質。This study aims to establish nursing records of admission care after the dialectical assessment and nursing in traditional Chinese medicine of inpatient care as well as Nursing Records Rriting Guidelines and Standards, and investigate the efficacy of clinical traditional Chinese medicine nursing staff's performance after the establishment of Traditional Chinese Medicine Nursing Standards. Besides, this study is expected to improve the quality of traditional Chinese medicine nursing care and professional ability of traditional Chinese medicine nursing staff. The study collected previous standards and contents of traditional Chinese medicine nursing records and nursing care plans worldwide at first. Afterwards, we conducted expert content validity through Delphi Method, especially correcting the contents and guidance of raditional Chinese medicine nursing records with expert opinion. After the authentication of expert validity, the results suggested the Content Validity Index (CVI) according the the expert opinion all reached 0.8. The complete nursing records in traditional Chinese medicine of inpatient care should comprise: (1) Patient's basic information, family history, the evaluation of 4 diagnostic methodologies, physical examination, the content and evaluation of nursing. (2) General records of dialectical nursing include a general examination from western medicine; signs of life (body temperature, pulse, breath and blood pressure); recording patients' pulse condition, tongue coating, mind, sweat, vomit and excretion through by 4 diagnostic methodologies of traditional Chinese medicine; patients' existing health and nursing problems; recording the nursing problems involved in doctor's advice, informing patients of record in important nursing problems. (3) Nursing records of severe patients: In addition to general nursing records, it should specifically record variation of patients' condition and specific measures. The study found out professional knowledge and ability in traditional Chinese medicine nursing of nursing staff could influence their quality of documentation. In order to ensure patients' care quality, we suggested nursing staff in traditional Chinese medicine units taking 7-course basic nursing in traditional Chinese medicine training with 9 credits for ability certification.