中醫住院護理病歷標準化之相關研究

鍾蕙如
長庚紀念醫院
隨著醫療科技的進步以及醫療型態快速的變革，民眾對醫療、護理服務品質之要求日益高漲(汪等，2003)，民眾多元化的求醫行為，使得傳統醫學逐漸受到重視（施、張，2000）。《皇帝內經》記載中國醫學是醫藥護不分，特別重視養生保健之道，秉持「三分治、七分養」的原則，除施治外，提供照護、調養的各種處方，成為現代中醫護理的緣起（張、劉，2000）。國家政策對中醫發展的重視與支持，中醫對護理人員的需求，及護理人員對中醫藥知識的需求增加;護理人員必須因應醫療的未來趨勢，學習中醫藥相關基礎知識於病患的照護上，以滿足國人健康需求並創造本土特色的護理模式（朱、廖、施，2000）。護理記錄為護理人員觀察評估病患身、心、靈前後變化過程書寫於病歷上，是護理病歷中不可缺少的內容，更是護理措施落實的具體表現，同時也反映了護士的業務水平與工作質量，因此，寫好護理記錄在護理工作中是十分重要的（高，2002）。然而我國中醫護理發展起步較晚，中醫護理相關病歷與護理記錄尚未針對中醫護理業務範圍建立一份完整的內容與規範。有鑑於此，本計畫係為建構中醫護理紀錄及護理計畫標準，並針對設立中醫護理標準後臨床中醫護理人員執行的成效進行相關探討，藉以提高我國中醫護理照護的品質與提昇中醫護理人員的專業能力。
關鍵字：中醫住院；中醫護理；中醫護理記錄

The Study for Nursing record standard of Inpatient care in Traditional Chinese Medicine Nursing at a Medical Center

Huei-Ru Jung
Chang Gung Memorial Hospital
Fast progression of the medical sciatic technology and the attitude to medical change, people ask the higher quality of medical treatment and nursing service day by day. (WANG 2003) Multifarious behaviors for seeking medical service make traditional medical science paid more attention gradually (SHIN, CHANG, 2000). In "The Yellow Emperor？HHHH？HHHHs Inner Classic", Chinese medicine didn？HHHH？HHHHt divide to medical and nursing; especially focus on the way to keep in good health. Adhere to the principle of three points on treatment and seven points on nursing. Besides medical management, offered various kinds of nurse prescriptions become the reason of modern Chinese medicine nursing. (CHANG, LIU, 2000)The government policies put attention and support on developing Chinese medicine. Chinese medicine needs the nursing staff and the nursing staffs demand for traditional Chinese medicine knowledge were increased. The nursing staff must follow the modern medicine tendency to study the basic knowledge of traditional Chinese medicine about patients care.
關鍵字：Traditional Chinese Medicine of Inpatient care；Traditional Chinese Medicine Nursing；Traditional Chinese Medicine Nursing records