Entry status understanding and entered content structuration in patient referral documents for information sharing in community cooperation

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  • 地域連携での情報共有に向けた診療情報提供書の記載状況把握と内容構成の構造化
  • チイキ レンケイ デ ノ ジョウホウ キョウユウ ニ ムケタ シンリョウ ジョウホウ テイキョウショ ノ キサイ ジョウキョウ ハアク ト ナイヨウ コウセイ ノ コウゾウカ

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Abstract

<p>To address the aging of society, the Ministry of Health, Labour and Welfare has been promoting the concepts of comprehensive community care systems and regional medical services. To fully achieve these concepts, it is essential to share information between attending physicians and the related local facilities, including acute hospitals. One of these details that should be shared is the information in patient referral documents (Format 11). In this study, with the view of standardizing patient referral documents for secondary use after patient referrals, we analyzed the actual entry status of 1,000 patient referral documents and examined the conformity of the entries to the current Format 11. Consequently, it was revealed that more than half of the cases had misplaced entries (i.e., entries that were not placed in the respective designated sections). To counter this problem, we categorized the referral purpose and the content construction of medical progress and structured Format 11 as an information scheme. This enabled us to construct a medical information-sharing system that automatically classifies input data by labeling and intensively accumulates information for secondary use.</p>

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