患者・医療者の診療記録共有

出版社: 中外医学社
著者:
発行日: 2022-12-05
分野: 医学一般  >  医学概論
ISBN: 9784498148345
電子書籍版: 2022-12-05 (1版1刷)
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診療記録は究極の個人情報であり,決して医療従事者の私的な記録やメモではありません.国際的には診療記録を患者と共有する流れが進んできており,日本においても近い将来,患者が当たり前のように診療記録へアクセスしているかもしれません.そのとき,個人としても病院としてもカルテを患者に見せられますか? 患者参加型医療が叫ばれて久しいですが,具体的に何から始めたらよいのか,臨床医目線でも病院管理者目線でも有用な一冊となっています.

目次

  • 1 ● 患者参加型医療とは何か─ 21 世紀の医療と患者参加
       背景
       患者参加型医療とは
       患者さんが自らの治療・ケアに参加する
       患者参加型医療を進めるうえでの課題

    2 ● 診療記録の共有をめぐる国際的状況
       患者ポータル
       診療記録共有“OpenNotes”
       患者ポータルの利用や診療記録の共有が医療の質に与える影響と課題
       わが国における診療記録共有と患者ポータル
       医療産業の国際化とデジタル活用

    3 ● 群馬大学におけるこれまでの経緯と診療記録の共有(積極的開示)の開始

    4 ● 診療記録とはなにか
       法的な位置づけ

    5 ● 診療記録の共有(積極的開示)の目的・正当性・問題点
       診療(記)録作成・保存・開示の法的義務
       診療記録の開示請求による開示
       診療記録の共有(積極的開示)の目的
       診療記録の共有(積極的開示)の正当性
       診療記録の共有(積極的開示)の実際的な問題点
       診療記録の共有(積極的開示)を前提とした診療録、看護記録の記載
       診療記録の共有(積極的開示)は本当に可能なのでしょうか

    6 ● 診療録や看護記録のあるべき姿

    7 ● 配慮すべき情報と共有(積極的開示)を求めることができる者
       すべてあますことなく開示すべきなのか
       誰が診療記録の共有(積極的開示)を求めることができるのか、
        また拒絶すべき場合があるとすればどのような場合か
       配慮情報
       配慮情報機能

    8 ● 検査結果などのハードコピーを患者さんなどにお渡しする場合の注意点
       コピーを患者さんにお渡しすることは推奨されるか
       どのような注意点があるか

    9 ● 診療記録の共有(積極的開示)の実際 〈対馬義人〉

    10 ● 3 年間の記録─医師・看護師の意識変化と患者さんの声
       医師の意識
       看護師の意識変化
       共有(閲覧)申し込み件数とアンケート結果
       入院患者さんに対するアンケート

この書籍の参考文献

参考文献のリンクは、リンク先の都合等により正しく表示されない場合がありますので、あらかじめご了承下さい。

本参考文献は電子書籍掲載内容を元にしております。

1 患者参加型医療とは何か - 21世紀の医療と患者参加

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2) Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the quality chasm : a new health system for the 21st century. National Academies Press ; 2001. (医療の質-谷間を越えて21世紀システムへ. 日本評論社 ; 2002)
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2 診療記録の共有をめぐる国際的状況

P.20 掲載の参考文献
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8) Centers for Medicare & Medicaid Services. Stage 2 Eligible professional meaningful use core and menu measures. http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf
9) Walker J, Leveille SG, Ngo L, et al. Inviting patients to read their doctors' notes : patients and doctors look ahead : patient and physician surveys. Ann Intern Med. 2011 ; 155 : 811-9.
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23) Bell SK, Mejilla R, Anselmo M, et al. When doctors share visit notes with patients : a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship. BMJ Qual Saf. 2017 ; 26 : 262-70.
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3 群馬大学におけるこれまでの経緯と診療記録の共有 ( 積極的開示 ) の開始

P.25 掲載の参考文献
1) 群馬大学医学部附属病院 医療事故調査委員会報告書. https://www.gunma-u.ac.jp/wp-content/uploads/2015/08/H280730jikocho-saishua.pdf

4 診療記録とはなにか

P.30 掲載の参考文献
1) 厚生労働省. 診療情報の提供等に関する指針. https://www.mhlw.go.jp/web/t_doc?dataId=00tb3403&dataType=1&pageNo=1

5 診療記録の共有 ( 積極的開示 ) の目的・正当性・問題点

P.43 掲載の参考文献
1) 厚生労働省. 診療情報の提供等に関する指針. https://www.mhlw.go.jp/web/t_doc?dataId=00tb3403&dataType=1&pageNo=1
2) 小松康宏. 患者参加型医療が医療の在り方を変える-21世紀異常のパラダイムシフト-. 国民生活研究. 2019 ; 59 : 56-80.
3) Saw KC, Wood AM, Murphy K, et al. Informed consent : an evaluation of patients' understanding and opinion (with respect to the operation of transurethral resection of prostate), J R Soc Med. 1994 ; 87 : 143-4.
4) https://www.jointcommission.org/assets/1/23/jconline_April_29_15.pdf
5) シッダールタ・ムカジー, 著. 野中大輔, 訳. 不確かな医学. 朝日出版社 ; 2018.

8 検査結果などのハードコピーを患者さんなどにお渡しする場合の注意点

P.81 掲載の参考文献
1) Saw KC, Wood AM, Murphy K, et al. Informed consent : an evaluation of patients' understanding and opinion (with respect to the operation of transurethral resection of prostate), J R Soc Med. 1994 ; 87 : 143-4.

10 3年間の記録 - 医師・看護師の意識変化と患者さんの声

P.102 掲載の参考文献
1) Walker J, Leveille SG, Ngo L, et al. Inviting patients to read their doctors' notes : patients and doctors look ahead. Ann Intern Med. 2011 ; 155 : 811-9.
2) Dendere R, Slade C, Burton-Jones A, et al. Patient portals facilitating engagement with inpatient electronic medical records : a systematic review. J Med Internet Res. 2019 ; 21 : e12779.

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