運用資訊系統降低血液透析記錄不完整率

Using Information Systems to Decrease the Percentage of Incomplete Hemodialysis Records

正確完整的照護紀錄，有利於醫護溝通、維持病患照護品質。本院血液透析中心手寫透析紀錄常有遺漏問題，經專案小組進行透析完整率為19.5%，經由訪談、歸納，確立主要原因為：透析照護和紀錄時間重疊，導致護理人員來不及寫；透析中護理人員未隨手記錄，事後又忘記補記錄；表單未整合，無固定評估時間；透析紀錄表格細小，容易遺漏；依個人判斷書寫處置紀錄。藉由簡化血液透析紀錄、制定紀錄書寫規範、建置血液透析紀錄資訊系統、舉辦教育訓練、制定查核及實施獎勵辦法。實行改善措施後，血液透析紀錄不完整率由19.5%降至3.8%。本專案的實施，確實改善單位護理同仁血液透析紀錄完整率低之問題，提升病人安全及照護品質。

Complete nursing records enable effective communication between medical personnel andcan improve the maintenance of patient care quality. Our Hemodialysis Center, which preparedhemodialysis records by hand, regularly experienced incomplete records. Therefore, a projectteam conducted a hemodialysis record survey and found that 19.5% of hemodialysis recordswere incomplete. We subsequently conducted interviews and generalized the results, fromwhich the causes of incompletion were identified: (a) the time for providing and recording thehemodialysis care overlapped each other, which renders the nursing personnel to haveinsufficient time to record properly; (b) nursing personnel did not make records immediatelyafter the hemodialysis treatments and often forgot to complete them; (c) there were multipletypes of forms that were not integrated and evaluated for effectiveness; (d) the hemodialysisrecord forms were small and easily missed; and (e) the nursing personnel were not providedwith a standard for recording their observations during the process. To alleviate these problems,the process of recording hemodialysis observations were simplified, record-writing standardswere formulated and implemented, a hemodialysis record information system was created,programs for continuing education on hemodialysis observational recordings were hosted, evaluation times of the information system were scheduled, and incentives for using the information system were implemented. After the aforementioned measures were followed,the percentage of incomplete hemodialysis records decreased from 19.5% to 3.8%. Byimplementing the project, we improved the incompletion rate of hemodialysis records andelevated patient safety as well as the care quality of hemodialysis patients.