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.