[[alternative]]Evaluation of nursing documentation quality before and after implementation of shift-to-shift report handoff information system

[[abstract]]在資訊科技日漸發展之下，醫療院所引進行動護理資訊系統已經成為趨勢，期望透過資訊科技可以幫助護理人員之照護效率和品質提升。引進行動護理交班系統之目的，主要是增加交班溝通之完整性，以提升病人照護之結果，但行動交班系統是否可以增加護理人員之照護護理紀錄內容品質，並未在台灣醫療界被研究過，故本研究目的在探討引進行動護理交班系統對護理紀錄內容品質造成之影響。本研究為前實驗性（Pre-experimental）研究，以某醫學中心病房護理人員為對象，在該醫學中心引進行動護理交班系統前後，利用護理紀錄品質審查活動，以JCAHO（Joint Commission on Accreditation of Healthcare Organization）病歷紀錄審查工具(closed medical review tool) 進行臨床護理紀錄內容審查，每月於住院十九個病房單位，各進行兩份現場病歷審查工作。研究先分析，不同護理單位之2010年1-7月每一病人平均每日所獲得之護理時數不同，對其單位之病歷紀錄內容平均執行率之影響，結果發現無顯著差異後（p =0 .193），另以2010年1-3月之各月病歷紀錄內容平均執行率，當作上線前資料，再以2010年5-7月各月病歷紀錄內容平均執行率當作上線後資料，利用Chi-Square比較各項監測指標之前後差異，研究結果發現，在25項病歷品質指標中，以指標「當疼痛確定，則進行廣泛性的評估，包括病人年齡、測量疼痛密度及疼痛性質、頻率、部位、期間」（p < .001）、「再評估結果應記錄在病歷上」（p = .006）和「正確縮寫書寫方式」（p = .025）達顯著意義。本研究機構之資訊交班系統內容欠缺護理計畫和措施之項目，造成在「再評估結果應記錄在病歷上」之項目資訊化後執行率反而變差；另交班系統設計含直接帶入醫師醫囑之資訊功能，幫助護理人員在交班時，針對確認疼痛後持續處理追蹤，該項指標因此執行率增加達顯著差異（p < .001），研究結果可做為其他機構規劃行動交班資訊系統內容設計參考，使其能朝向更實用且同步增加護理交班和紀錄品質之功能。[[abstract]]The information system technology has been developed day by day. The hospital to implement the mobile nursing station for health care has become a trend in recent years. The use of the information technology system has been expect to help the nursing staff to improve the care efficiency and quality, respectively. The main purpose of using the shift report system is to increase the communication and to improve the integrity of healthcare during the shift work change process. Whether this system can improve the charting quality or not, so far, there have been no published studies in Taiwan on these technology use in health care. Therefore, the goal of this study was to exam the impact on charting quality when the mobile inter-shift system has been introduced. The study was the pre-experimental research to involve ward nursing staff in a medical center as the participants. JCAHO (Joint Commission on Accreditation of Healthcare Organization）closed medical review tool was applied before and after the medical center implemented the inter-shift system, and there were 19 wards unit to be evaluated monthly. The study started on examining the charting content by varied nursing hours on each patient in the nursing units from January to July in 2010, and no significant (p =0.193) result was found. The before (January to March) and after (May to July) data in 2010 were collected for comparison purpose and were analyzed by Chi-Square. Among 25 evaluated charting quality items, results showed that when pain was identified, the patient would have comprehensive assessment including the patients age, pain intensity, characteristics, frequency, location, and duration (p < .001),re-assessment being documented in the patient record (p = 0.006) and correct abbreviation writing (p = 0.025). Due to no nursing items related to care plan and interventions, the completed ratio of re-assessment being documented was decreased and while the physician order entry was integrated into the system, the pain assessment rate was increase. The finding can be the references for the design on inter-shift information system in other institutions to improve both shift- change process and charting quality improvement