Development of a Nursing Documentation Model that Allows for Open Medical Record Access

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Nursing documentation in Japan lacks a framework or regulation under the Public Health Nurse, Midwife, and Nurse Law. For reimbursement calculation purposes, nursing care plans and progress records are necessary, and the content and format is decided by each individual institution. In terms of open medical record access, nursing records are considered part of the medical record, and are regarded as private information. Thus, standardized nursing documentation that serves the purpose of providing open medical record access is needed.In this study, in order to help open access to medical records, we've identified issues related to nursing records, derived principles from relevant organizations and legal statements, and created a conceptual model. This model identifies the purpose and content of nursing record documentation. Nursing records provide evidence that nursing staff fulfill their ethical and occupational responsibilities, as well as quality assurance. Also, in the era of electronic medical records, it is necessary to have a patient-centered, standardized record that the entire healthcare team can utilize. A nursing documentation standard was created by selecting a generalizable framework for Japan, and then adding elements and principles that followed relevant organizations' guidelines. This standard was implemented in 52 hospitals in Japan. Since creating a standard would be difficult with merely criteria, specific examples of record documentation were also presented. This model aimed to not only offer open access to medical records but also shorten time spent on documentation.