@inproceedings{oai:tau.repo.nii.ac.jp:00000024,
 author = {前田, 樹海 and 北島, 泰子 and 古澤, 圭壱 and 山下, 雅子 and MAEDA, JUKAI and KITAJIMA, YASUKO and FURUSAWA, KEIICHI and YAMASHITA, MASAKO},
 book = {医療情報学, Japan journal of medical informatics},
 issue = {Suppl.},
 month = {},
 note = {This paper discusses how nursing records should be and presents a tentative idea for the nursing records in the era of interprofessional cooperation, from the position that data and information are analyst- or problem-solver-dependent matters.

Originally nursing plan should be written in the framework of the nursing process based on the assessment by nurse from patient data. However, various forms such as “Standard Nursing Plan”, “NANDA Nursing Diagnosis related Nursing Plan”,“NIC Linkage”, and “Critical Path” have been prevalent as a form of nursing records.

On the other hand, interprofessional cooperation is advancing and medical information system in which multiple medical professions are involved is common, so, nurses is compelled to use these nursing plans as well as original nursing-processbased nursing plan. We have to consider if this situation contributes to efficiency in recording or we can call these new types of nursing records “nursing record”.

With using disease/treatment-wise standard nursing plan, for example, once the name of the disease is determined, nursing plan for the patient would be chosen automatically. Under this scheme, we face the issues whether nursing plans can be determined before nurses visit the patient, whether nurses can take responsibility for the plan being not based on their assessment, and that hindsight bias relating to the assessment would take place.

According to Blum (1986), “data” are the uninterpreted items given to an analyst or problem solver, and “information” is a collection of data elements organized to convey meaning to the user. Applying these definitions to each profession’s record, data and information each profession enters, and the entries they made only have to be understood among the profession. With this concept, it would be one idea that nursing care starting with doctor’s diagnosis should be written on the form for doctors, and nursing care based on the assessment derived from data collected by nurses should be written on the form of
nurses as nursing record., 【2015年第35回医療情報学連合大会（第16回日本医療情報学会学術大会）でのポスター発表】


<研究のポイント>
・患者のカルテの書き方には様々な記録方法がある。
・医師、看護師、薬剤師など様々な職種が連携するために様々なカルテの書き方をしなければならず、効率的でない。
・記録方法の中には、医師による確定診断があれば、看護計画が決まってしまうような、「患者と一度も会わずに看護計画が決まる」ものもあり、問題と考えられる。

[次のようにしてはどうか]
・各職種が責任をもってデータ・情報の管理を行うために、看護記録は看護独自のアセスメントに基づくケアのみを記録する。
・医師の診断に基づく看護師のケア記録は医師の診療録に記載する。},
 pages = {1166--1167},
 publisher = {日本医療情報学会},
 title = {多様化する看護記録の整理に向けた試論},
 volume = {35},
 year = {2015},
 yomi = {マエダ, ジュカイ and キタジマ, ヤスコ and フルサワ, ケイイチ and ヤマシタ, マサコ}
}