JP2003114929A - Medical practice management recording form - Google Patents

Abstract

PROBLEM TO BE SOLVED: To provide a medical practice management recording form capable of appropriately evaluating the flow of a medical practice and the final result thereof. SOLUTION: This medical practice management recording form is constituted of a hospitalization day medical management chart which is equipped with a column where medical act items to be performed on each hospitalization day and the achievement goal items of a patient are described, a column where results with respect to those items are recorded, and a column where codes indicating the classifications and factor types of abnormality items about which the medical acts to be performed on that day or the goals of the patient can not be achieved or abnormality items which deviate largely from the target values and the concrete contents are described, and an abnormality value totaling chart equipped with a column where the medical practice items and the final target items of the patient described in the hospitalization day medical management chart are described and a column where the codes indicating the factors of the abnormality items about which the medical practices to be performed or the targets of the patient can not be achieved or the abnormality items which deviate from the target values are entered for all the hospitalization days.

Description

Detailed Description of the Invention

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to a form for recording items for medical management of inpatients in a hospital and their records.

[0002]

2. Description of the Related Art As medical records in hospitals, medical record cards called so-called medical records or No. 2 paper are used. This card is divided into two columns on the left and right. The left column shows the medical history, causes, major medical conditions, etc., and the right column describes the prescription, surgery, treatment, etc., along with a record, which is used as a reference material for the next examination and treatment. I was there. However, the way medical records are written varies from doctor to doctor, and there was no possibility of developing a database between major hospitals and affiliated hospitals. It takes a lot of effort to pick up the quality such as statistics, medical tendency of doctors and nurses from this chart.

On the other hand, a system called an electronic medical record has been developed in order to improve the efficiency of storing and reading the medical record. In this system, the contents are input by a keyboard instead of handwriting on the existing medical record, It can be managed and searched by a computer, but it does not exceed the functions of conventional medical records.

In recent years, the entire treatment plan and medical records from the time a patient is hospitalized to the time he or she is discharged are described on a paper called a clinical path, and the details of treatment on each day are described on a daily flipping paper. Systems for implementing and recording are being proposed and adopted. For example, in a conventional clinical path, outcomes (achievement target items), assessments (achievement criteria observation items), and tasks (instruction contents) are described according to a schedule.

[0005]

The above-mentioned conventional recording method is merely a list of facts and evaluations, and the series of medical procedures, that is, instructions, executions, evaluations, interventions, etc., are not clear. In addition, since the achievement goal is not clear, it cannot be said that the evaluation was done properly, and it is difficult to incorporate medical data into the system for analyzing the cause of failure and the system for quality improvement. The problem to be solved by the present invention is to provide a medical management record form that can appropriately evaluate a series of flows of medical actions and achievement of goals.

[0006]

[Means for Solving the Problems] In order to solve the above problems, the medical management record form of the present invention shows standard medical actions during hospitalization for diseases, post-operations, and symptoms, and is used as an instruction book. Based on the staff overview pass, a column that describes the medical action items and patient achievement target items that should be performed on each day of hospitalization, a column that records the results of those items, and the medical treatment that should be performed on the day. For an abnormal item that fails to achieve the action or patient's achievement target or deviates from the target value, a medical management table by admission date with columns for describing the type of the item and the type of cause and the specific content thereof And a column in which the medical action items and patient achievement target items listed in the medical management table for each day of hospitalization are described, and the medical practice and patient achievement targets that cannot be achieved or are out of the target values. The abnormal items, is made of an abnormal value schedule in which a column to be filled for all admission date code representing the cause.

In the present invention, the achievement goal of the treatment called an outcome is clearly defined and a criterion is added to this. If the goal was not achieved, this was taken as an outlier, the cause was investigated, and a solution was taken. Moreover, in order to grasp the overall frequency of occurrence of abnormal items and achievement of the goal, an abnormal value summary table was created. In order to share information, a column was created for each occupation (doctor, nurse, pharmacist, nutritionist, laboratory technologist, physiotherapist, etc.).

[0008] Particularly important goals are set as priority goals and devised so that they can be watched. Conventional medical records are poorly logical, and the cause, result, evaluation, and countermeasures of a series of medical procedures were unknown at a glance, but this made it possible to improve such things. In addition, in the conventional recording method, there was no system for tabulating and analyzing the cause of failure, but an abnormal value tabulation table was created to supplement this drawback. Further, in the conventional clinical path, since there is no code in the medical procedure, it takes a lot of labor to collect the data, but in the present invention, the achievement level of the main medical procedure can be easily collected.

[0009]

BEST MODE FOR CARRYING OUT THE INVENTION Embodiments of the present invention will be described below with reference to the forms shown in FIGS. Take laparoscopic cholecystectomy as an example.

FIG. 1 shows a path in the overview format, which is usually called a clinical path in Japan. 2 is an enlarged view of part a of the pass sheet of FIG. 1, FIG. 3 is an enlarged view of part b, FIG. 4 is an enlarged view of part c, and FIG. 5 is an item of the pass sheet of FIG. Figures and 6 are 5-8
FIG. 7 is an enlarged view of the day and FIG. 7 is an enlarged view of the 9th to 12th days.

Also in this format, the achievement goal and the priority goal are specified. Enter the adaptation criteria in column a.
Exclude criteria (states that should not be used) in column b.
Goal setting (discharge criteria) is entered in column c. In column d, the outcomes (achievement target items), namely patient status (H), daily activities (F), knowledge / education (K), possible complications (C), and other (O) are scheduled to be discharged from the hospitalization date. Describe as a daily schedule until the day. Priority goals should be written in bold and should be more prominent than others. In column e, enter the assessment (observation criteria for success criteria) as a daily schedule. The observation items include items specific to the patient's disease, such as systolic blood pressure, heart rate, chest pain, respiratory distress, arrhythmia, oxygen saturation, and water balance. The task (instruction content) is described in the f column. Tasks include treatment, treatment, inspection, medicine, rehabilitation, cleanliness, excretion, diet,
Classified into education / teaching coordination and additional instructions,
The specific schedule for each instruction is described. However, the overview type pass sheet that describes such contents shows the whole picture of treatment and cannot be a detailed record of medical treatment.

FIG. 8 shows a medical management table for every hospitalization date. FIG. 9 is an enlarged view of the upper half of this medical management table for every hospitalization date, and FIG. 10 is an enlarged view of the lower half thereof. G shown in FIG.
In the column, the items for the day of the outcome described in the overview path of Fig. 1 are described, and in the column h, the full name and signature of the person in charge of examination and treatment are provided for each time. There is. The full name and signature are included to position them as official medical records. i
In the column, enter the examination / procedure, in column j, enter the patient status, and in k
The columns are filled in with the functions, and the m columns are filled with knowledge and education. In the code table on the right, the achievement goal code (O
C) An entry column n, an abnormality code (VC) entry column o, a time entry column p, and a content / action entry column q are provided.

As described above, in the medical management table for every hospitalization date, the medical actions to be performed on the day and the achievement goals of the patient are organized and recorded, and the person in charge performs instruction work based on this and evaluates the degree of achievement. . If it is achieved, it will be finished only by checking, but if it is not achieved, it will be marked in red, the code number will be entered in the code table in the n, o columns on the right, the time will be entered in the p column, and this will be evaluated. , Medical instruction required in column q,
Make additions. At this point, the part that is particularly important is the central issue of the day, and in order to call attention to all medical staff, the r column in the lower row is in free format, and shared information and other comments are entered. By doing so, it is possible to prevent the “missing” of the recording and to respond in real time if the target cannot be achieved.

The achievement target code OC is provided for the purpose of effectively performing anomaly analysis and also for the purpose of supporting computerization.
The standard items are listed.

In this embodiment, the items are classified into five categories and the code numbers are given. T (Treatments): Examination, treatment H (Health): Patient state F (Function): Living movement K (knowledge): Knowledge, education C (Complication): Complication O (Other): Others

Code numbers are entered in necessary items in the medical management table for every hospitalization date shown in FIG. A code number may be assigned to each category for each department-specific item. The following are examples of basic codes in each category.

T: Inspection / treatment 01 Blood collection 02 Urine collection 03 X-ray 04 ECG 05 CT scan 06 MRI 07 ultrasound 08 Oral 09 drip 10 oxygen 11 artificial respiration 12 Intravascular catheter placement 13 Antibiotic test 14 Meals 15 balloon catheter 16 clean 17 Gauze exchange 18 Thread removal 19 drain 20 medication instruction 21 Life guidance 22 Nutrition guidance 23 Discharge guidance

H: Patient status 01 Body temperature 02 blood pressure 03 oxygen saturation 04 pulse 05 consciousness 06 Meal 07 urine 08 defecation 09 sputum 10 wounds 11 Drain drainage 12 Pain

F: Living activity 01 walking 02 meal 03 excretion 04 conversation

K: Knowledge, education 01 function 02 Disease 03 drug 04 Treatment / Surgery 05 nutrition 06 discharge

C: Complications 01 MRSA 02 pressure ulcer

O: Other (unique problem) 01 Transference adjustment

FIG. 11 shows an abnormal value totaling table, which is a table for totaling items that could not achieve the target, that is, abnormal items and causes. The code number is in the left column, the date column is in the upper column, and only those with an abnormality are marked on this. Marks are marked with A, B, C, and D according to the abnormality classification, which allows the cause classification to some extent. The anomaly classification makes it possible to identify the location of the cause as follows.

A: Patient / Family 1: Patient's condition (physical factors) (1) Exacerbation of past disease (poor control of past disease due to surgery, etc.) (2) Postoperative complications (pulmonary complications, infections, etc.) (Ileus, leak, etc.) (3) Delayed healing of wounds (such as incomplete closure of wounds) 2: Patient / family decision-making 3: Patient / family compliance (eg, did not take the drug as instructed)

B: Medical staff 1: (Doctor's) instructions (missing instructions, adding instructions, etc.) 2: (Determination) (Drain removal, postponement of thread removal, etc.) 3: Coping with staff (not coping as directed)

C: Hospital 1: Medical materials / medical equipment 2: Bed control 3: Schedule (tests cannot be performed during consecutive holidays, medical examinations at academic conferences, etc.)

D: area 1: Transfer to another hospital (such as the bed being transferred to is not empty) 2: Stay home (family circumstances, acceptance issues, etc.)

The abnormal code for each cause is set and entered in the abnormal value totaling table. For example, if there are many A or D in the abnormal code of the abnormal value summary table, it can be judged that the problem does not improve on the hospital side, but if there are many B, there is a problem in the medical staff's coping method. It can be seen that measures such as studying the communication method, staff retraining, and relocation are necessary. If there are many Cs, it is understood that the problem should be dealt with on the hospital side.

This is not limited to specific patients, but 20 to 30
It is possible to identify problems in medical management by aggregating examples, and taking measures against them will lead to quality improvement.

Since there is no code in the past for such totaling, it is necessary to extract it from various records, which is extremely laborious, but this not only makes it possible easily, but also facilitates digitization.

[0031]

As described above, the present invention has the following effects. (1) Establishing Logicality of Records That is, the form of the present invention has a clear achievement level by a logical check method. Moreover, since the flow of work can be grasped at a glance and is logical, the explanation ability is high. (2) Sharing information By using this sheet for all occupations such as doctors, nurses, pharmacists, nutritionists, laboratory technicians, and physiotherapists,
It is easy to capture the events in progress, especially the progress of priority goals. (3) Clarification of priority goals The critical areas for treatment are generally determined, and on the other hand, it becomes possible to set goals and make efforts to achieve them as an entire team. In the past, such priority goals have not been clarified. (4) Ease of data collection Codes are assigned to major medical procedures, which makes it easy to collect data on a single form without the need to look at all medical records in the past. (5) It has a logical structure that can withstand the release of medical records, and has an expression format that anyone can see. (6) Computerization is easy The goal is clear, the degree of achievement is clear, and the coding of major medical practices makes it an expression format suitable for the electronic medical record environment, which is fundamentally different from conventional electronic medical records.

[Brief description of drawings]

FIG. 1 is an explanatory diagram showing a pass sheet in an overview format.

FIG. 2 is an enlarged view of a portion of the pass sheet shown in FIG.

FIG. 3 is an enlarged view of part b of the pass sheet of FIG.

FIG. 4 is an enlarged view of a portion c of the pass sheet shown in FIG.

5 is an enlarged view of the items on the pass sheet of FIG. 1 and the first to fourth days.

FIG. 6 is an enlarged view of the pass sheet of FIG. 1 on days 5-8.

FIG. 7 is an enlarged view of the pass sheet of FIG. 1 on days 9-12.

FIG. 8 is an explanatory diagram showing a medical management table for each hospital day.

9 is an enlarged view of the upper half of the medical management table for each hospital day shown in FIG. 8. FIG.

FIG. 10 is an enlarged view of the lower half of the medical management table for each hospitalization date in FIG.

FIG. 11 is an explanatory diagram showing an abnormal value totalization table.

   ─────────────────────────────────────────────────── ─── Continued front page    (72) Inventor Hiroshi Matsuda             6-22-18 Izumi, Kumamoto City, Kumamoto Prefecture (72) Inventor Jiro Machida             3-17-46 Takahira, Kumamoto City, Kumamoto Prefecture (72) Inventor Toshiro Yonehara             Kumamoto City Kumamoto Prefecture 3-6-21 Itomate (72) Inventor Koichi Nakao             4-17-38 Izumi, Kumamoto City, Kumamoto Prefecture (72) Inventor Goro Honda             2-4-14 Hakkei Mizutani, Kumamoto City, Kumamoto Prefecture (72) Inventor Yumiko Michibata             107 Tsuchigawaracho, Kumamoto City, Kumamoto Prefecture (72) Inventor Sachiko Toino             Kumamoto Prefecture Kumamoto City Ishiharacho 301-46 (72) Inventor Yukiko Ishida             7-6-31 Hanazono, Kumamoto City, Kumamoto Prefecture (72) Inventor Reiko Nakagawa             Kumamoto City, Kumamoto Prefecture 7-16-34-202 (72) Inventor Mitsuaki Kanasaki             2-3-14 Kusunoki, Kumamoto City, Kumamoto Prefecture (72) Inventor Hideo Kawashima             12-83 Kokufuhonmachi, Kumamoto City, Kumamoto Prefecture

Claims (4)

[Claims] 1. A medical procedure to be performed on each day of hospitalization based on the staff overview pass used as an instruction sheet, which indicates standard medical procedures during hospitalization in terms of illness, surgery, and symptoms. Items and items to be achieved by the patient, columns to record the results for those items, and medical items that should be performed on the day and abnormal items that fail to achieve the patient's achievement target or deviate from the target value, A medical management table for each hospital day provided with a code for indicating the type of the item and a type of cause and a column for describing its specific content, and medical action items and patient achievement goals described in the medical management table for each hospital day Fill in the column in which the item is described and the code indicating the cause of the abnormal item that cannot achieve the medical treatment or the achievement target of the patient or is out of the target value for all hospitalization days Medical management record form consisting of an abnormal value schedule in which a column. 2. The medical management table for each hospital day is displayed with attributes that can be visually distinguished from the characters of other items, among the medical action items and the achievement target items of the patient, the important achievement target for the applicable disease. The medical management record form according to claim 1, further comprising a description column for indicating whether or not the priority achievement target has been achieved. 3. The medical management table for each day of admission is provided with a column for entering the name of the person who performed the medical treatment described in the medical treatment item and a signature, according to claim 1 or 2. Medical management record form. 4. The code, which is recorded in the abnormal value summary table and represents the cause, is caused by the patient / family, which means that the condition or family of the patient is the cause, and the instruction, decision, and coping with the medical staff. There is a medical staff that means that there is, a hospital that means that it is due to hospital equipment such as medical materials, medical equipment, bed control, schedules, and that the bed at the transfer destination is not available or home treatment is the cause. It is classified into the meaning area and the area.
Medical management record form described.