病歴管理の現状と展望

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書誌事項

タイトル別名
  • The Situation and the Prospect of the Management of Medical Records in Hospitals
  • ビョウレキ カンリ ノ ゲンジョウ ト テンボウ

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説明

The management of medical records in Japanese hospitals are divided into three types: (I) centralized management system medical records are collected into the medical record office and statistics are made there; (II) central storage system …medical records are collected into the medical record office, but statistics are not made; (III) storage system by each division of clinical services…medical records are not collected into the centralized medical record office but stored separately in each clinical division.<br>Table 1 shows the change in the percentage of the patterns of the management of medical records among the mentioned three types between 1904 and 1970. As shown in Table 1, the percentage of the hospitals with type (I) has increased, whereas that of the hospitals with type (III) has decreased. As regards the technics used in the management of medical records, most hospitals rely on manual procedure, and some hospitals use simple machines like card-sorter or card-selector. But it seems to be new trend that some groups of hospitals under the same administration use jointly one computer of the EDP service center to accomplish statistics from case abstracts of medical records.<br>Five influential factors on the improvement of the management of medical records are supposed to be as follows:<br>1. Increased necessity of clinical information system for comprehensive patient care in each unit hospital<br>2. Increased importance of medical records as fundamental data of hospital administration and clinical care administration<br>3. Recognized importance of medical audit in hospital<br>4. Recognized necessity of community hospital program by each hospital<br>5. Increased necessity of the efficient feed-back system of clinical data to the medical research<br>The following policies should be implemented to improve the management of medical records<br>1. Establishment of authorized education for medical record librarians<br>2. Legislation of the qualification and registration of medical record librarians<br>3. Establishment of a centralized medical record office in each hospital<br>4. Establishment of a hospital medical care information center in the national level<br>5. Introduction of a central dictation system into hospitals<br>6. Establishment of scientific research program based upon discharge data reports.

収録刊行物

  • 医療

    医療 26 (11), 955-959, 1972

    一般社団法人 国立医療学会

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