診療録と薬剤管理指導記録の一体化に関するアンケート―医療チームで情報を共有することの有用性―

Abstract

In the Chukyo Hospital, two separate records of patient information had been kept by doctors and nurses and pharmacists in the past. Doctors and nurses had written it in medical records and pharmacists in pharmaceutical care records and patient compliance instruction records. These records have been unified recently and we carried out a questionnaire survey to see if doing this had been beneficial or not. Persons responding were 10 doctors (in neurosurgery and neurology) and 25 nurses The questionnaire revealed that the unified records had made patient information more accessible and shareable and had made it easier to view medication history at a glance. On the other hand, the greater amount of data and thicker files resulting from the unification were seen as a problem. However, overall, the unification of the medical records, pharmaceutical care records and patient compliance instruction records was seen as useful.