建構中醫護理紀錄模式

陳麗華
台北市立中
中醫是我國傳統醫學，深受民眾肯定與喜愛。政府於民國84年7月將其納入健保門診給付，87年10月開始試辦中醫住院服務。但至目前為止，中醫護理仍無一套具有中醫特色的護理評估及護理紀錄模式。本計畫擬邀請專家學者，以中醫理論為基礎，將現有的護理評估及護理紀錄表單修正，對護理人員進行教育訓練，使護理人員能熟悉並應用。從護理人員在臨床的應用，我們逐案討論，不斷修正，然後再應用於病人身上。最後我們設計問卷，了解並分析護理人員使用的能力。我們希望此計畫可以建構護理評估及護理紀錄模式，以提高醫護間溝通的共識與護理的專業。
關鍵字：中醫住院,護理紀錄

Establishment of Nursing record in TCM

chen lei hua
Taipei Municipal Hospital of Traditional Chinese Medicine
our traditional medicine，it is affirmed by the people。The government afforded the Chinese medicine clinic from 1995，and provided admission service from 1998。But as far to now，we do not have a coincident nursing assessment tool and nursing record form，the medical personnel can not communicate well each other。 We will invite professionals to revise the nursing assessment and record which we use now based on the Chinese medicine theory。Then，we provide on-job education，the nurses will be familiar with the new form。During application period，we have to discuss with the professionals and nurses，and maybe revise the assessment and record。Finally，we will assess the nurse‘ ability on application and satisfication to the new form。 We hope the establishment of nursing assessment and record will promote the communication between medical personnel and service quality。
關鍵字：admission service,nursing record