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

• Main Authors: Chien-Yen Hsu, 許騫燕
• Other Authors: Ting-Ting Lee
• Format: Others
• Language: zh-TW
• Published: 2014
• Online Access: http://ndltd.ncl.edu.tw/handle/84660456386010262594

碩士 === 國立臺北護理健康大學 === 護理研究所 === 102 === 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.