Patient access to medical records: problems and strategies for inpatient charts

Fasing the impending introduction of patient access to medical charts, we have attempted to include a more substantial description of medical activity in specific areas. Using the guidelines published jointly by the Ministry of Health and Welfare and the Tokyo Metropolitan Office in October 1998, the staff of the medical records division examined and evaluated the layout and description of items on individual hospital charts, with excellent results. To encourage the continued improvement of medical chart recording in the future, incentives should be implemented to avoid insufficient descriptions, encourage regular chart inspections, and promote education regarding the need for a systematic approach to charts and chart recording.