Uto Yumiko, Iwaanakuchi Takashi, Muranaga Fuminori, Kumamoto Ichiro
Department of Medical Informatics, Graduate School of Medical and Dental Sciences, Kagoshima University.
Stud Health Technol Inform. 2013;192:1036.
In Japan, POS (problem oriented system) is recommended in the clinical guideline. Therefore, the records are mainly made by SOAP. We developed a system mainly with a function which enabled our staff members of all kinds of professions including doctors to enter the patients' clinical information as an identical record, regardless if they were outpatients or inpatients, and to observe the contents chronologically. This electric patient record system is called "e-kanja recording system". On this system, all staff members in the medical team can now share the same information. Moreover, the contents can be reviewed by colleagues; the quality of records has been improved as it is evaluated by the others.
在日本，临床指南推荐采用问题导向系统（POS）。因此，病历主要按照SOAP格式书写。我们开发了一个系统，其主要功能是使包括医生在内的各类专业工作人员能够将患者的临床信息作为同一记录录入，无论患者是门诊患者还是住院患者，并能按时间顺序查看内容。这个电子病历系统被称为“电子患者记录系统”。在这个系统上，医疗团队的所有工作人员现在都可以共享相同的信息。此外，同事可以对内容进行审核；由于他人的评估，病历质量得到了提高。
