兒科電子化護理紀錄之改善方案

Improvement Plan for Pediatric Electronic Nursing Records

本單位因護理紀錄電子化初推展，常出現護理紀錄不完整，經稽核發現完整性達82分之比率僅76%，故急待改善。經現況分析發現：護理紀錄書寫完整性缺乏共識、未使用e化護理工作車交班、專科護理計劃不足、未即時書寫以致忘記書寫護理紀錄、可供參考之護理紀錄書寫範例不足等問題、稽核人員未確實指正。綜合以上缺失，自2012年1-10月進行改善方案，提出策略為舉辦在職教育、推行用e化護理工作車交班、制定三項專科護理計劃、製作常見缺失查檢表、貼叮嚀小卡、制定護理紀錄書寫範例、當面說明及輔導等。經執行後合格率提升至96%。希望藉此專案推行之經驗分享，提供臨床推行電子化護理紀錄之經驗參考。

Because of the early promotion of electronic records, nursing records often appear incomplete. After auditing, we found that the integrity of nursing records up to 82 points only 76%, so we need to improve urgently. Several problems were found after observations, such as a lack of consensus about nursing records integrity, unused E-nursing car for shift, a lack of specialized care plan, immediate documentation not conducted due to forgetfulness, sample nursing records were inadequate, and auditors didn't point out mistakes for correction. Based on the above problems, we start an improvement program from January to October 2012. The strategies we used include in-service education, implementation of the E-nursing work car for shift, development of three specialized nursing care plan, making a common deletion checklist, attachment of asmall card to exhort nurses, development nursing record samples, face to face descriptions and counseling. After the implementation, we can meet the integrity of nursing records up to 96%. We hope to share the experience of the project implementation and to provide clinical experience of electronicnursing record for reference.