Learning Objective 1: Shift-to-shift report handoff information system had changeed Nursing documentation quality.
Learning Objective 2: The finding can be the reference as the design on inter-shift information system for other institutions to improve both shift- change and charting quality.
Methods: the research is the Pre-experimental research to take the floor nursing staffs in a medical center as the object. Before and after the medical center introduced the inter-shift system , evaluating the charting content according to JCAHO closed medical review tool.Chi-Square was used to examine the difference of these two data
Results: The result showed the remarkable significance on “When pain is identified, the patient is referred or a comprehensive assessment is performed, appropriate to the patient’s age and measuring pain intensity and quality such as pain character, frequency, location, and duration.”(p < .001), “Reassessments are documented in the patient’s record”. (p = .006)“When required by the organization, the ward of an entry can be identified”(p = .025)among 25 evaluating targets on charting quality.
Conclusion: The information integrity ration turned out not well on “Reassessments are documented in the patient’s record” due to the lack of the nursing care pans and action in the information shift changed system. Obviously, integrity ration showed significant difference (p < .001)when the system included the information function connects to the physician prescription.
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