| Item type |
会議発表論文 / Conference Paper(1) |
| 公開日 |
2016-09-22 |
| タイトル |
|
|
タイトル |
看護記録の内容の煩雑化回避と情報網羅の両立に向けて |
|
言語 |
ja |
| タイトル |
|
|
タイトル |
Towards nursing records maximizing information contained and minimizing nurses' input. |
|
言語 |
en |
| 言語 |
|
|
言語 |
jpn |
| キーワード |
|
|
言語 |
en |
|
主題Scheme |
Other |
|
主題 |
nursing record |
| キーワード |
|
|
言語 |
en |
|
主題Scheme |
Other |
|
主題 |
SOAP |
| キーワード |
|
|
言語 |
en |
|
主題Scheme |
Other |
|
主題 |
time-oriented record |
| キーワード |
|
|
言語 |
en |
|
主題Scheme |
Other |
|
主題 |
complication avoidance |
| キーワード |
|
|
言語 |
en |
|
主題Scheme |
Other |
|
主題 |
cover all the information |
| 資源タイプ |
|
|
資源タイプ識別子 |
http://purl.org/coar/resource_type/c_5794 |
|
資源タイプ |
conference paper |
| 著者 |
北島, 泰子
山下, 雅子
前田, 樹海
辻, 由紀
KITAJIMA, YASUKO
YAMASHITA, MASAKO
MAEDA, JUKAI
TSUJI, YUKI
|
| 抄録 |
|
|
内容記述タイプ |
Abstract |
|
内容記述 |
The purpose of this study was to explore factors of weakness in nurses' use of the SOAP format on the nursing record in their daily nursing service. In addition, to propose an idea for an optimum method for keeping nursing records. The structure of the SOAP format was set up to utilise extraction of problems style. Subjective Data or Objective Data were unable to function in isolation due to underived Assessment and Plan. However, information of isolation data can sometimes signal a serious problem or mean something.
We researched the 25 nurses working in a unit of a hospital, and asked them whether they had had an experience of discarded information actually turning out to be of importance. In one instance, a nurse gave attention to the behavior of one
patient, though it was difficult to record by use of the SOAP format on the nursing record. Afterward that patient became fatal, so that the behavior of the patient at that time was of significance for later.
The SOAP format was superior in terms of enabling the record of nurse's observations and thinking to be written briefly. At the same time it was fraught with possibilities of loss of key information. It is getting even more complicated if nurses have to record the patients' data all of the time in chronological order. Electronic health record system has increased in the past few decades. It is suggested that by use of Folding mode and Development mode of electronic health record system it may become almost possible to create a clear, concise and detailed record. |
| 書誌情報 |
ja : 医療情報学
en : Japan journal of medical informatics
巻 35,
号 Suppl.,
p. 636-639,
発行日 2015
|
| 出版者 |
|
|
出版者 |
日本医療情報学会 |
| ISSN |
|
|
収録物識別子タイプ |
ISSN |
|
収録物識別子 |
02898055 |
| 書誌レコードID |
|
|
収録物識別子タイプ |
NCID |
|
収録物識別子 |
AN10024228 |
| 権利 |
|
|
権利情報 |
日本医療情報学会 |
| 情報源 |
|
|
|
関連名称 |
第35回医療情報学連合大会 35th JCMI(Nov.,2015)(第16回医療情報学会学術大会) |
| 関連サイト |
|
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|
識別子タイプ |
URI |
|
|
関連識別子 |
http://rylab.hcc.h.u-tokyo.ac.jp/jcmi35/ |
|
|
関連名称 |
第35回医療情報学連合大会(第16回医療情報学会学術大会) 2015年11月1日～4日 沖縄県宜野湾市 |
看護記録の内容の煩雑化回避と情報網羅の両立に向けて (632.2 kB)
