Simulation of medical record disclosure aiming at completion of medical records

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  • Shimasaki Akemi
    National Hospital Organization, Himeji Medical Center, Internal Medicine Department
  • Nomura Chie
    National Hospital Organization, Himeji Medical Center, Medical Safety Control Division
  • Ustumi Hisako
    National Hospital Organization, Himeji Medical Center, Case Management Division
  • Fujita Takako
    National Hospital Organization, Himeji Medical Center, Case Management Division
  • Maeda Shyoichi
    Tokyo University, Graduate School of Medicine, Medical Safety Research Institute

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Other Title
  • カルテ記載の充実をめざした模擬カルテ開示
  • カルテ キサイ ノ ジュウジツ オ メザシタ モギ カルテ カイジ

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Abstract

To understand the importance of medical records, our study team simulated the disclosure of medical charts. Residents, the general risk manager, a clerical staff, the person in charge of resident training program and the health information manager of Himeji Medical Center took part in this study. Modified real medical charts were used to protect patients' personal data. In role-play settings we took the part of applicants, physicians incharge and superior doctors, and concluded with a discussion about the writing of charts.<BR>This method had much significance: 1. Recognition of the importance of medical records. 2. Residents learn the bases of medical recording. 3. Inspection of the content of medical charts. 4. Promotion of teamwork in medical treatment. 5. Preparation of true medical chart disclosure.<BR>Furthermore we also held seminars, during which we judged the quality of medical record written by residents. In-house inspections have shown that residents record medical charts better than superior physicians. The simulation of medical chart disclosure proved to improve the quality of medical records.

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