完整的護理記錄是病人安全及醫療照護品質的基本要素，有利於醫療團隊的溝通，因此記錄的完整與確實是有其必要性。專案小組於2014年7-9月查核護理記錄書寫完整性，僅達80.7%，未達閾值。經現況分析後確立原因為：忙碌未及時書寫、對書寫內容認知標準不同、缺乏諮詢人才庫、未宣導及公佈查核結果、缺書寫記錄範例和在職教育及提醒標語等因素。針對以上原因提出解決對策有：製做提醒小卡及護理記錄書寫範例、公佈書寫不完整名單及查核結果、病房會議加強宣導、舉辦在職教育、成立護理記錄書寫案例討論會及諮詢人才庫等七項。實施後護理紀錄書寫完整率由80.7%提昇至97%。期本專案之改善策略，能作為未來護理紀錄書寫改善照護。

A complete nursing care record is an essential element of patient safety and medical care quality, which is conducive to communication within a medical team. Therefore, it is necessary to achieve completeness and thoroughness of those records. The Ad hoc group conducted an inspection on nursing care record writing completion, only reaching 80.7%, lower than the threshold during the period of July to September, 2014. Through the analysis of the current situation, the established reasons are: too busy to write records promptly, different writing content knowledge standards, the lack of a consulting talent pool, inspection results not being advocated and announced, the lack of writing record examples and in-service education and reminder slogans, and other factors. Targeting the above reasons, the strategies proposed to solve these problems include: producing reminder cards and nursing care record writing samples, announcing the list of incomplete writing and inspection results, strengthening ward meeting advocacy, organizing in-service education, setting up nursing care record writing case seminars and a consulting talent pool, seven items in all. After implementation, the nursing care record writing completion rate increased from 80.7% to 97%. The project improvement strategy is expected to serve as a model for future nursing care record writing and improve care.