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

日本的护理文件缺乏《公共卫生护士、助产士和护士法》下的框架或法规。出于补偿计算的目的，护理计划和进度记录是必要的，其内容和格式由每个机构决定。在开放病历访问方面，护理记录被视为病历的一部分，并被视为私人信息。因此，需要标准化的护理文件，以达到开放病历检索的目的。在本研究中，为了帮助开放病历检索，我们识别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，并创建了概念模型。该模式明确了护理病历记录的目的和内容。护理记录提供了护理人员履行道德和职业责任以及质量保证的证据。此外，在电子病历时代，有必要有一个以患者为中心的标准化病历，整个医疗团队都可以使用。通过选择适用于日本的通用框架，然后添加遵循相关组织指南的要素和原则，创建了护理文档标准。该标准在日本的52家医院实施。由于仅凭标准就很难制定标准，因此还提供了记录文件的具体例子。这一模式的目的不仅是提供对医疗记录的开放访问，而且还缩短了记录所花费的时间。

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.