Appendices

This research investigates the effectiveness of an intervention program aimed at improving nursing documentation practices, focusing on enhancing the quality, accuracy, and cultural sensitivity of records. The study incorporates a range of tools and methods, including roleplay scenarios, digital simulations, and hands-on exercises, which address common documentation errors such as incomplete patient histories, misclassification in SOAP notes, and delayed or inaccurate follow-up entries. Assessment tools like the Documentation Quality Assessment Tool (DQAT), Nursing Documentation Self-Efficacy Scale (NDSES), and NASA Task Load Index (NASA-TLX) were utilized to evaluate pre- and post-intervention improvements in documentation skills, confidence, and cognitive load. The results indicate significant gains in documentation quality, including improved assessment completeness, diagnostic accuracy, and the timeliness of records, with the experimental group showing substantial and sustained improvements. These findings highlight the effectiveness of structured, roleplay-based interventions and digital tools in fostering better nursing documentation practices, ultimately enhancing patient care and safety.

本研究旨在评估一项旨在优化护理文书书写实践的干预方案的有效性，重点聚焦于提升护理记录的质量、准确性与文化敏感性。本研究采用了多种工具与方法，涵盖角色扮演场景、数字化模拟及实操训练，用于纠正常见的护理文书书写错误，例如患者病史记录不全、SOAP记录（SOAP notes）分类错误、随访记录延迟或不准确等问题。研究采用文书质量评估工具（Documentation Quality Assessment Tool, DQAT）、护理文书书写自我效能量表（Nursing Documentation Self-Efficacy Scale, NDSES）以及NASA任务负荷指数量表（NASA Task Load Index, NASA-TLX）作为评估工具，对干预前后护理人员在文书书写技能、职业信心及认知负荷方面的改善情况进行测评。研究结果显示，护理记录质量得到显著提升，具体包括评估内容完整性、诊断准确性及记录及时性的改善，且实验组的改善效果显著且具有持续性。本研究结果证实，基于结构化角色扮演的干预方案与数字化工具可有效优化护理文书书写实践，最终提升患者照护质量与医疗安全。