資訊護理紀錄系統導入之使用者評值探討

Nursing records are nurse-prepared records of the patient care process. Integration of nursing records is essential for avoiding data repetition and errors that may endanger patient safety. Use of information technology helps to improve the correctness and integrity of nursing records, integrate care information, simplify the process, and improve the quality of care. The purpose of this study was to obtain the evaluations of users and differences in the record review process before and after an information technology intervention. We utilized two approaches: a questionnaire to assess the effectiveness of the nursing record system based on the information system success model for user evaluation, and analysis of the difference in the nursing record review score of hospitals before and after the information technology intervention. The questionnaire contained 143 questions under different categories, namely, information quality, net benefit, user satisfaction, service quality, and system quality; the scores for each category were 2.68, 2.65, 2.55, 2.51, and 2.46, respectively. All information factors were strongly positively correlated with user satisfaction and net benefit. Nursing interventions, hospital nursing discharge instructions, and instruction documentation were significantly improved aspects of record quality after implementation of the information system. The users' perceptions of the information system were positive, suggesting that the quality of information factors should be improved when implementing information technology to ensure that the most favorable outcome is obtained using the system. In addition, improvement in nursing record quality may appear only in some items at the beginning of system deployment, and thus, follow-up evaluations should be continued.