Nursing Record Innovations Aimed at Harmonizing Structured Clinical Knowledge Among Doctors and Nurses

作者：Satoko Tsuru, Tetsuro Tamamoto, Hitoshi Furuya, Akihiro Nakao, Mari Fukuyama, Kouichi Tanizaki, Naohisa Yahagi · 发表于：Studies in health technology and informatics · 年份：2020 · DOI：10.3233/shti200238 · 被引用次数：5 · 研究领域：Pharmacy and Medical Practices、Clinical practice guidelines implementation、Palliative Care and End-of-Life Issues

Hospitalization expenses account for a high proportion of national medical care expenditure in Japan. In 2015, the total national medical care expenditure in Japan was 42.4 trillion yen, and hospitalization expenses were 15.6 trillion yen (36.8%). Therefore, it is necessary to reduce hospitalization expenses. The labor cost of physicians and nurses accounted for about 1/3rd of all expenditure of general hospitals in 2015. Moreover, the personnel cost of nurses accounted for about 1/5th of all expenditure, indicating that it has a marked impact on hospital management. Nurses spend a lot of time completing descriptive records; however, the quality of such records is poor. It is necessary to improve nurse's records to make them highly accessible and reduce the amount of time nurses spend producing records. The objective of this study was to improve the processes underlying record-keeping by nurses in order to harmonize structured clinical knowledge among doctors and nurses. We created 778 Patient Condition Adaptive Path System (PCAPS) items, covering all of the clinical departments that were registered for the PCAPS content master. The resultant masters will be standardized by sharing them with hospitals that adopt the "Team Compass" application. We were able to summarize all of the information in clinical progress sheets because we could link the information described in electronic medical records with that described in Team Compass. Therefore, it became easy to collect informa...