{"created":"2023-06-20T15:53:16.353155+00:00","id":7834,"links":{},"metadata":{"_buckets":{"deposit":"5492dd77-1d28-4596-85e8-1e3696939165"},"_deposit":{"created_by":28,"id":"7834","owners":[28],"pid":{"revision_id":0,"type":"depid","value":"7834"},"status":"published"},"_oai":{"id":"oai:redcross.repo.nii.ac.jp:00007834","sets":["172:173:229"]},"author_link":["27877","27879","8018","27825","27824","27880","27822","27823","27826","27878"],"item_10001_biblio_info_7":{"attribute_name":"書誌情報","attribute_value_mlt":[{"bibliographicIssueDates":{"bibliographicIssueDate":"2015-05-01","bibliographicIssueDateType":"Issued"},"bibliographicPageEnd":"48","bibliographicPageStart":"43","bibliographicVolumeNumber":"32","bibliographic_titles":[{"bibliographic_title":"日本赤十字社和歌山医療センター医学雑誌"},{"bibliographic_title":"Medical journal of Japanese Red Cross Society Wakayama Medical Center","bibliographic_titleLang":"en"}]}]},"item_10001_description_5":{"attribute_name":"抄録","attribute_value_mlt":[{"subitem_description":"診療記録監査は、平成２２年よりオーダリング電子カルテ等システム運営委員会（以下、委員会という）において、医師部門、看護師部門、薬剤師部門、リハビリテーション部門、薬剤部門、栄養課部門の各部門別に年２回実施しており、監査結果は回数を重ねる度に各部門とも全体的に良くなってきている。また、監査結果については電子カルテ上で参照可能としており、診療録記録に対する意識向上につなげている。\nこれからの監査は、委員会で決定した各部門の監査項目に対してであり、監査法方法は、電子カルテシステム（以下、電子カルテという）では記載内容と記載回数について監査し、入院患者ファイルではファイルに挟まれている紙媒体の署名や日付の有無、また、記載の場合は押印の有無等を監査した。しかし、電子カルテでオーダされたものが、入院患者ファイルに編綴されているかどうかの監査は実施していないことから、平成26年3月1日から６月30日退院分の退院患者6,303名について、オーダとオーダに対する紙媒体の整合性の量的監査を医療情報管理課で実施した。\n「オーダがあるのに紙媒体がない」場合とその逆の場合もあり「転倒・転落に関する説明・同意書（以下、転倒・転落という）においては、一部病棟で『評価が0点の場合は印刷しない』独自のルールが存在していた。電子カルテ端末以外の端末から出力している説明・同意書では、患者基本情報があやまって印字される事例もあり、いくつかの問題点が見つかった。ここでは、監査結果と今後の課題について報告する。","subitem_description_type":"Abstract"}]},"item_10001_full_name_3":{"attribute_name":"著者別名","attribute_value_mlt":[{"nameIdentifiers":[{}],"names":[{"name":"Nishioka, Naoko"}]},{"nameIdentifiers":[{}],"names":[{"name":"Miwa, Sunao"}]},{"nameIdentifiers":[{}],"names":[{"name":"Ono, Chiaki"}]},{"nameIdentifiers":[{}],"names":[{"name":"Morimoto, Haruka"}]},{"nameIdentifiers":[{}],"names":[{"name":"Kimura, Ken"}]}]},"item_10001_publisher_8":{"attribute_name":"出版者","attribute_value_mlt":[{"subitem_publisher":"日本赤十字社和歌山医療センター"}]},"item_10001_source_id_9":{"attribute_name":"ISSN","attribute_value_mlt":[{"subitem_source_identifier":"1341-9927","subitem_source_identifier_type":"ISSN"}]},"item_10001_version_type_20":{"attribute_name":"著者版フラグ","attribute_value_mlt":[{"subitem_version_resource":"http://purl.org/coar/version/c_970fb48d4fbd8a85","subitem_version_type":"VoR"}]},"item_creator":{"attribute_name":"著者","attribute_type":"creator","attribute_value_mlt":[{"creatorNames":[{"creatorName":"西岡, 直子"}],"nameIdentifiers":[{}]},{"creatorNames":[{"creatorName":"三輪, 順"}],"nameIdentifiers":[{}]},{"creatorNames":[{"creatorName":"大野, 千彰"}],"nameIdentifiers":[{}]},{"creatorNames":[{"creatorName":"森本, 遥"}],"nameIdentifiers":[{}]},{"creatorNames":[{"creatorName":"木村, 建"}],"nameIdentifiers":[{}]}]},"item_files":{"attribute_name":"ファイル情報","attribute_type":"file","attribute_value_mlt":[{"accessrole":"open_date","date":[{"dateType":"Available","dateValue":"2015-08-17"}],"displaytype":"simple","filename":"Vol.32 43-48ｐ.pdf","filesize":[{"value":"1.8 MB"}],"format":"application/pdf","licensetype":"license_note","mimetype":"application/pdf","url":{"label":"Wakayama32_08","url":"https://redcross.repo.nii.ac.jp/record/7834/files/Vol.32 43-48ｐ.pdf"},"version_id":"5303686c-119a-4efb-bc5f-2d4c907308f7"}]},"item_keyword":{"attribute_name":"キーワード","attribute_value_mlt":[{"subitem_subject":"診療記録監査","subitem_subject_scheme":"Other"},{"subitem_subject":"量的監査","subitem_subject_scheme":"Other"},{"subitem_subject":"整合性","subitem_subject_scheme":"Other"},{"subitem_subject":"e-文書法","subitem_subject_scheme":"Other"},{"subitem_subject":"診療録","subitem_subject_scheme":"Other"},{"subitem_subject":"Medical record audit","subitem_subject_language":"en","subitem_subject_scheme":"Other"},{"subitem_subject":"Quantitative audit","subitem_subject_language":"en","subitem_subject_scheme":"Other"},{"subitem_subject":"Consistency","subitem_subject_language":"en","subitem_subject_scheme":"Other"},{"subitem_subject":"e-Documents Act","subitem_subject_language":"en","subitem_subject_scheme":"Other"},{"subitem_subject":"Medical records","subitem_subject_language":"en","subitem_subject_scheme":"Other"}]},"item_language":{"attribute_name":"言語","attribute_value_mlt":[{"subitem_language":"jpn"}]},"item_resource_type":{"attribute_name":"資源タイプ","attribute_value_mlt":[{"resourcetype":"journal article","resourceuri":"http://purl.org/coar/resource_type/c_6501"}]},"item_title":"入院患者ファイルの量的監査について：現状報告と今後の課題","item_titles":{"attribute_name":"タイトル","attribute_value_mlt":[{"subitem_title":"入院患者ファイルの量的監査について：現状報告と今後の課題"},{"subitem_title":"Quantitative audit  for inpatient files : Status report and future challenges","subitem_title_language":"en"}]},"item_type_id":"10001","owner":"28","path":["229"],"pubdate":{"attribute_name":"公開日","attribute_value":"2015-08-17"},"publish_date":"2015-08-17","publish_status":"0","recid":"7834","relation_version_is_last":true,"title":["入院患者ファイルの量的監査について：現状報告と今後の課題"],"weko_creator_id":"28","weko_shared_id":-1},"updated":"2023-06-20T19:31:31.938123+00:00"}