指導病人學習如何促進及維持自身的健康狀態，是護理過程最重要的工作之一，護理指導則是達到此目的之主要方法。現因資訊科技發達，透過電子病歷資料庫之建立及利用臨床決策支援護理資訊系統，能客製化個別性之護理指導，讓病人從入院到出院的過程，皆獲專業照護。本文以南部某醫學中心急診、加護病房、普通病房所有臨床護理師為對象，將護理過程紀錄，經由資訊系統介入將護理計畫與衛教指導對應，以落實臨床護理衛教指導完整性。透過統整全院的衛教指導，進行分類，找出各病房常用的衛教指導內容，再由每月督導長、病房自稽、N3資深護理師三組人員以護理紀錄稽核表來稽核臨床護理人員紀錄評分，作為護理指導紀錄評鑑項目完整性之比較分析，運用回溯性審查法，48個月共11,980筆評分資料進行分析，資料採用描述性統計與單因子變異數分析。結果顯示，從2012年護理指導衛教系統建置後，觀察三類單位在不同年度之稽核護理衛教指導紀錄完整性分數呈現逐年顯著上升（p＜.05）。顯示資訊化導入後，對臨床護理衛教指導紀錄完整性是有幫助的；建議未來醫學中心可朝多元化擴充衛教資源發展，如醫療體系結合民間電信數位電視，提供遠距健康服務掌握健康資訊，俾能服務病人更無縫接軌。

Instructing patients to promote and maintain their own health is the most crucial job in nursing. Nursing guidance is a primary method for achieving this goal. The development of information technology allows tailored nursing instruction to be provided by establishing electronic medical databases and by using a clinical decision support information system. All patients receive enhanced professional care during hospitalization. Our research used nursing process documents of nurses in an emergency department, an intensive care unit, and a general ward at a Southern Taiwanese medical center. We used an information system to match a nursing plan with health education guidance and implemented the integrity of clinical nursing and teaching guidance. The hospital's health education guidance was categorized and used in wards that were subsequently selected. The auditing team-comprising a supervisor, a ward representative, and an N3 senior nurse-undertook monthly inspections of clinical nursing care records using the audit tables from nursing records. Finally, a total of 11,980 audit results collected over 48 months were analyzed using descriptive statistics and one-way analysis of variance to assess the integrity of nursing instruction records for hospital accreditation on the retrospective review. Our results demonstrated that, after the establishment of the nursing guidance education system in 2012, the integrity scores of nursing health education guidance records for three departments significantly improved year by year (p ＜ .05). The integrity of clinical nursing health education records was improved with information technology. We suggest that the medical center extend education resources, such as the medical system combined with private telecom digital TV, and then provide remote health services to deliver a range of information about health.