需要長期醫療的慢性病及老年病患不斷增加，要提高護理品質，必須 給予持續及整體性之護理計畫，因此，在病患住院初期即需開始評估其長期之醫 療照顧需要，有計畫給予所需之衛生教育及指導，不但可減少佔床率及醫療成 本，更可增進出院病人居家的自我照顧能力。 由本院於82年所做之「護理服務品質評鑑」之調查得知，有系統執行出院 護理計畫之達成率僅為19.56%，而出院護理計畫中所給予之指導及衛教均零散 於各項護理計畫中，對於病患出院後長期需要，則缺乏周全的計畫與記錄。 護理部品管小組根據現況分析及需求，設計了新的出院護理計畫表，內容包 括病患居家照顧及支持系統之評估，病患長期照顧需求之評估及出院當日衛教需 要之評估等三大項，於民國82年7月開始使用出院護理計畫表，實施一年後所 做之「護理服務品質評鑑」之調查發現：有系統執行出院護理計畫之達成率提昇 到29.71%，並經訪視出院病患評值出院衛教達成率為76.92%，所有臨床使用單 位皆認為出院護理計畫表之使用，確實可作為其在計畫出院護理時工作之指引， 滿足病人的需要，提昇護理品質。

　　　　　The number of chronic and elderly patients who need long-term care has been increasing. For the purpose of continuing care and providing high quality nursing, systematic discharge planning is required. Therefore, the nurse should assess the patient's needs at the start of hospitalization, followed by providing health care instruction. This not only decreases the length of hospital stay and medical costs, but also improves the patient's self-care ability and capability once discharged. In 1993, appraisal of nursing quality revealed that the systematic discharge planning efficiency rate was 19.56%, obviously not a satisfying grade. This is mainly because all patients' health education programs are distributed into separate nursing records and care plans, and there is a lack of integral long-term care planning and records for discharge. According to the situation analysis and necessity of discharge planning for continuing care, the Quality Assurance Committee of the Nursing Department has developed a discharge planning form, which includes assessment on a patient's self-care capability, functional ability, support system, long-term care needs and health regimen. Since July 1993, the discharge planning form has been used within 22 units of the hospital. One year later, we again undertook the nursing quality appraisal project and noted that the efficiency rate was elevated to 29.71%. Visits made to patients on the day of discharge revealed that their compliance rate of discharge health education was 76.92%. This form is generally considered useful as a guide to facilitate the discharge planning, meet patients' continuing care needs and promote nursing care quality.