[[alternative]]Impact on an individualized nursing record for the implementation of an operating nursing documentation system

[[abstract]]本研究目的為探討導入手術護理記錄系統後對個別化護理記錄的影響。個別化護理是護理的核心價值，其特徵是能考量到病人的需求，並包含病人生理、心理及社會等層面，而個別化護理記錄則是指詳實記錄病人所獲得的個別化護理照護。但是由於個別化護理會受到多種因素影響因此較難被量化，因此國內外皆缺乏文獻探討護理記錄之個別化情況，尤其是針對手術護理記錄系統。因此本研究採病歷回溯法收集手術護理記錄系統導入前後三個月共480份的手術護理記錄，先以內容分析法(content analysis)確認手術室個別化護理記錄應具備的主題，再以專家效度訂定成手術護理記錄個別化查核表，之後稽核手術室個別化護理記錄的內容分佈及執行率。本研究發現手術室個別化護理記錄應具備10個主題及24項查核項目，其中最常見的主題為皮膚完整性、手術傷口及生理需求，且以「有標準化術語的記錄欄位」記錄頻次多於「無標準化術語記錄欄位」，而較罕見的主題是植入物及自費昂貴醫材。之後，針對個別化護理記錄之「有標準化術語的記錄欄位」且記錄頻次為高的查核項目計算其執行率，而「無標準化術語記錄欄位」且記錄頻次過低的項目則分析其導因，發現其影響因素有三種，分別為未落實、易遺漏及使用不當的變通方法。但是整體而言，導入手術護理記錄系統後確實能提昇個別化護理記錄的執行率，並且達到統計上顯著差異。最後，總結來說，手術室護理人員多數能支持病人具有個別化的生理需求，但是針對病人的心理需求則較少記錄，而且幾乎能完成有標準化術語的記錄欄位，但對於無標準化術語的記錄則會因為組織制度、人為因素及系統問題而導致記錄頻次偏低，因此建議可藉由訂定個別化護理記錄規範、人員在職教育、系統設計及功能修改等改善個別化護理記錄頻次過低的情形。[[abstract]]The purpose of this study is to explore the impact on an individualized nursing record for the implementation of an operating nursing documentation system. Individualized nursing care is a core value, and the individualized nursing records mean a well-documented individualized nursing care for patients. However, because the impact on individualized nursing care will be dependent on a variety of factors, thereby making it more difficult to be quantified, because of the lack of domestic and international literature for discussion of individualized nursing records, especially for operating nursing documentation systems. That is why this study uses the chart backtracking method for the collected implementation of an operating nursing documentation system before and after for three months, with a total of 480 operating nursing records. Firstly, to use content analysis to confirm the operating individualized nursing record should have a theme, then the experts validity will formulate the operating individualized nursing record checklists, after that, to review its content and implementation rate. The study found that operating individualized nursing record should have 10 themes and 24 items, including the most common theme that is skin integrity, surgical wound, and physiological needs. The rarest themes are implants, and patient’s own expensive medical material. After that, the focus of the high frequency items calculated its rate of implementation, whereas the low frequency items analysis of its reasons, and found that there are three factors, not real, easily missing, and the use of inappropriate workarounds. However, after the implementation of the operating nursing documentation system, it will not only improve the operating individualized nursing record implementation rate, but also achieve a statistically significant difference