The cold winter has arrived.It is a season when snow falls in November, and the flu's epidemic starts early, so it is easy to get sick.
By the way, I think you have once been to the hospital.So you don't show much of the "medical records" written by doctors and nurse.Have you ever wondered, "What exactly is written in that chart?"What if a patient can freely see his chart?The author, who is a doctor and actually writes the medical record every day, let's talk a bit about his true intentions.Please be bored on holidays and for a little bit of trivia.
Carte is officially called "medical record" in Japanese.It means that doctors and others record the contents of medical treatment.It seems that the word "chart" is originally the word Karte (paper) in German.It's the same as English Card.
Since I am a doctor working in a hospital surgery, I write medical records every day at the hospital.However, we do not basically show the patient, unless there is a special disclosure request.It is only when showing the test results such as CT tests, X -rays, blood sampling tests, etc. when explaining the medical condition.
However, the content written in the medical record is only the patient.From the patient's point of view, the question comes to the question, "Why can't I see it when I'm written?"I heard that question, so I came up with this article.
In fact, the chart is full of encryption.When I first practiced at the hospital as a medical student, when I read the medical record, I couldn't understand half of the written content.So even if you read the general public, I think it will be the same.Anyway, there are many abbreviations, and the abbreviations are completely different depending on the department.
Let's give an example.The abbreviation of "MR" is a mental development delay for psychiatrists and pediatricians, and for radiologists, MRI is an abbreviation for MRI, and for circulatory internal medicine doctors (Mitral R RR).Egurgitation), and all doctors have various meanings, such as medical information representatives of pharmaceutical companies.
I often see medical records written by doctors in other departments, but the same surgical surgery still makes sense, but it is often the case that other departments do not understand.
And as mentioned in the example, the words used are not only English.We, the surgeon, use German (Modoki).Therefore, those who are fluent in English and German will not make sense even if they look at the medical records.
I memorized the names of organs in German and Latin in college, but since I became a doctor, the surgeon medical records were difficult.For example, write "PUS+" or "EITER+" that pus is coming out of scratches.Both mean pus, and "+" means "yes" or "positive".Probably this is not a doctor other than a surgeon.
And the terrible thing is the English and German docked Japanese English -speaking words?There are many things likeThe word "Margenve" is the best, "Margen" means the stomach, and the "tube" means tube.Translated literally, it is a "stomach tube", which refers to a tube that puts it from the nose to the stomach.In Japanese, it is exactly "nasal stomach tube" and "nasal tube" in English.
In the past, there were many cases where the characters were too dirty and the instructions were incorrectly transmitted to the nurse.Even now, if you take out old medical records and read them, you may need time to decrypt.
Recently, even though it is a medical record, the "electronic medical record" doctors have entered the computer considerably.The medical record that I wrote on the previous paper is called "paper chart", and for young doctors who only know "electronic medical records", as a training when a server Fivees down in the event of a disaster, etc.There is about it.
Now, thanks to the electronic medical record, it is very easy to read even if you enter.It's painful to see an elderly doctor hitting the keyboard with one index finger in both hands.
The electronic medical record has a manner to write.This is the method called soap.
S I'm very Fiveod today.Appetite has come out.I will also practice walking.
O bt 36.5 degrees HR 70BP 130/74 Meal 8 % intake 1 Defecation
A The postoperative course is Fiveod.The amount of dietary intake has also been stable.
P rehabilitation continuation.The drip ends.
This is the same no matter where you Five all over Japan, and it is quite popular in large hospitals.
S (Subject) is what the patient actually said, O (Objective) is an objective data such as body temperature and blood pressure, A (Assessment) is evaluated, and P (Plan) is planned.
With this system, the data related to the seemingly complicated patients is different to make it easier to see.This is easy to read.
As we have seen above, many difficult terms appear in the medical records, and even the same doctor cannot understand if they have different specialties.So it's not so Fiveod, so don't use the abbreviations or terms that can only be understood by themselves.Carte records medical treatment, sometimes used to consider patient treatment, but also has a public document.In the event of a medical accident or a medical mistake, it is used as evidence.
Here is one question.The question is, "Is it impossible for patients to access their medical records while treating them in real time?"Even if it is not in real time, it may be possible to show it once every three times in an outpatient hospital, once a week if you are in the hospital.
These three can be considered, given the reasons why this is not currently being done.
1, Because it is meaningless to show only the medical record
2, because treatment may have a negative effect
3, I can't hide even if I make a mistake
「1, Because it is meaningless to show only the medical record」
This is exactly what I have explained.It is easier to understand if the doctor meets directly and explains while showing the test results.In fact, the hospital is doing so.
「2, because treatment may have a negative effect」
Is this a bit hard to come?Calte is not to write anything that is not necessary for treatment, but everyone will be anxious if you see characters such as "extremely harsh" or "need to be careful."If you look only at such characters in a situation where the explanation is not enough, there is a risk of unwilling anxiety.But maybe, including that, you may have to think about disclosure if the patient wants.However, doctors may not be able to write if they think "patients are watching".It is "worst situation" or "bad possibility".Doctors always keep them in mind, but if you write such a thing, patients may panic.It's a very difficult problem.
In relation to this, even if the Ministry of Health, Labor and Welfare's guidelines issued by the Ministry of Health, Labor and Welfare, even if "the symptoms, prognosis, treatment progress, etc. are provided sufficiently to patients, patients are sufficiently explained to patients.When it has a serious psychological effect on the person and has a negative effect on subsequent therapeutic effects ( *).In such a case, there is a scene where it is better not to show the medical record.
「3, I can't hide even if I make a mistake」
This is why it should not be.The current electronic medical record has a fairly detailed record, so it is almost impossible to hide mistakes by falsifying the chart.Although it is not a "white giant tower", rewriting the medical records in the "paper chart" era can never be done by the electronic medical record.In the electronic medical record, everyone, when, which computer, and all are recorded, are all recorded.
Nevertheless, someday, the patient may be free to look at his medical record and participate in the description.That may increase the quality of medical care and fill the gap between doctors and patients.With the improvement of transparency and disclosure of information in all industries, the medical industry must think about this.
(reference)
* Guidelines for providing medical information, etc.
http: // www.MHLW.Five.JP/SHINGI/2004/06/S0623-15M.html