本專案目的為改善末期腎病病房出院護理指導，藉以提昇護理人員對出院準備服務執行之完整性，並提供病患及照顧者個別性護理指導，進而提昇滿意度。此專案自93年9月10日至10月21日針對腎臟科病房末期腎病病患及照顧者、護理人員，以實地觀察、訪談、問卷調查及查閱護理記錄等方式收集資料。歸納問題為：護理人員執行出院準備服務作業完整性為54.9%，其中未定期執行高危篩選評估；護理指導執行率為84.3%，住院中護理指導記錄為51.9%、出院護理指導記錄為3.5%；病患及照顧者對護理指導了解為69.2%；滿意度為74.6%。經由專案介入措施有修訂末期腎病病患之出院計劃、護理指導記錄範本及護理指導輔助工具、擬定「護理人員出院準備服務作業完整性」之監控、並制定每週高危篩選評估作業，結果顯示：執行出院準備服務作業之完整性為90.7%，定期高危篩選評估完成率100%；各項護理指導執行率為97.0%，住院中護理指導記錄為91.2%，出院護理指導記錄完整性為72.6%；病患或照顧者對護理指導了解程度為96.7%，滿意度為84.5%。藉由此專案推動，強化護理人員落實出院護理指導及滿意度。

The aims of the intervention program were to promote discharge planning of end-stage renal disease (ESRD), to enhance comprehension of nursing care, to provide guidance to patients and caregivers, to increase satisfaction level, and to decrease length of stay. The program took place from Sep. 10 to Oct. 21 in 2004. Data were collected from ESRD patients, caregivers, and nursing staff in nephrology department. Several problems were identified after interviewing and observing patients as well as reviewing charts. The analysis indicated that the completeness of discharge planning was 54.9%, inability to screen high risk group and practice nursing guide was 84.3%, inpatient nursing guide was 52.1%, discharge nursing guild was 3.4%, patients?and caregivers?understanding of nursing care was 69.2%, and satisfaction level was 74.6%. The intervention program included revised discharge planning of ESRD, formal record of nursing guide, assistant device of nursing guide, monitoring the comprehension of planning, weekly screening and evaluation of high risk groups. The results showed that the completeness of practice increased to 90.7%, completeness of screening increased to 100.0%, practice guide increased to 97%, inpatient nursing record increased to 91.2%, discharge nursing record increased to 72.6%, understanding of nursing guide increased to 96.7%, and satisfaction level increased to 84.5%. The intervention program, in conclusion, enhanced practice of discharge planning of nursing staff, promoted self-care ability, and increased satisfaction of patients.