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

开发允许开放病历访问的护理文档模型

• 批准号: 10672253
• 负责人: IWAI Ikuko
• 金额: $ 1.54万
• 依托单位: St. Luke's College of Nursing
• 依托单位国家: 日本
• 项目类别: Grant-in-Aid for Scientific Research (C)
• 财政年份: 1998
• 资助国家: 日本
• 起止时间: 1998 至 1999
• 项目状态: 已结题
• 来源: https://kaken.nii.ac.jp/grant/KAKENHI-PROJECT-10672253/
• 关键词: access to medical records; standardized nursing record; development of a nursing documentation; 診療情報の提供; 診療記録・看護記録開示; 診療記録の開示

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.

日本的护理文件缺乏《公共卫生护士、助产士和护士法》的框架或规定。为了计算报销，护理计划和进度记录是必要的，内容和格式由各机构决定。在开放病历访问方面，护理记录被视为病历的一部分，被视为私人信息。因此，需要标准化的护理文档，以提供开放的医疗记录访问。在这项研究中，为了帮助医疗记录的开放，我们确定了与护理记录相关的问题，从相关组织和法律声明中推导出原则，并创建了一个概念模型。该模型确定了护理记录文件的目的和内容。护理记录提供了护理人员履行其道德和职业责任以及质量保证的证据。此外，在电子医疗记录时代，必须有一个以患者为中心的标准化记录，供整个医疗团队使用。通过为日本选择一个可概括的框架，然后添加遵循相关组织指导方针的元素和原则，创建了护理文件标准。这一标准在日本的52家医院实施。由于仅凭标准很难制定标准，因此还提出了记录文件的具体例子。这种模式的目的不仅是提供对医疗记录的开放访问，而且还缩短了花在文档上的时间。

项目成果

診療情報開示に不可欠な視点 目的、インフォームド コンセント、自己決定

医疗信息披露的基本观点：目的、知情同意和自决

• 发表时间: 2007
• 期刊: 看護 51(13)
• 作者: 岩井郁子;岩井郁子
• 通讯作者: 岩井郁子

カルテ開示時代の看護記録をどう考えるか

病历公开时代我们该如何看待护理记录？

• 发表时间: 2007
• 期刊: 看護管理 9(7)
• 作者: 岩井郁子