4) 診療情報の開示と電子カルテ（シンポジウム 診療情報の提供における諸問題, 第561回新潟医学会）

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  • シンリョウ ジョウホウ ノ カイジ ト デンシ カルテ
  • A Role of Electronic Medical Record System for Disclosing Medical Information to Patients

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This review focuses on the role of electronic medical records for disclosing medical information to patients. ln the case of a request by a patient, most Japanese national university hospitals have started disclosing information regarding medical practice. This would include the patients overall medical record, clinical examinations, radiological images, and inpatient practice charts written by nurses. Patients today are interested in the medical records that summarize all practice relating to their case. Unfortunately, most existing medical records have not been written in a standardized format, that is, SOAP format (Subjective, Objective, Assessment and Planning), and common medical terms have not been used by many doctors. Current medical records are not sufficient for disclosing medical information to patients. The application of an electronic medical record system enables a hospital to standardize the format of medical recording and refine the medical terms used in practice, by means of templates for predetermined items. The advantage and disadvantage of such a system will be discussed in this review.

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