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篇名
整合護理資訊系統建立提升血液透析記錄之完整性
並列篇名
Use Nursing Information System to improve the Completeness Rate of the Hemodialysis Nursing Records
作者 賴怡欣 (Lai-Yi Shin)曾芃廩 (Peng-Lin Tseng)林妮妮 (Ni-Ni Lin)鄭維真 (Wei-Chen Cheng)蔡玉梅 (Yu-Mei Tasi)陳寶珍
中文摘要

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。

 

英文摘要

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.

 

起訖頁 036-054
關鍵詞 完整性血液透析護理資訊系統completenesshemodialysisNursing Information System
刊名 臺灣腎臟護理學會雜誌  
期數 202109 (20:1期)
出版單位 臺灣腎臟護理學會
該期刊-上一篇 提昇末期腎病患者抉擇腹膜透析意願度之專案
該期刊-下一篇 透析中的動態增能時光~ 一位肌少症透析病人阻力運動訓練的照護經驗
 

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