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Development of the electronic patient record system based on problem oriented system
Yumiko Uto1, Takashi Iwaanakuchi, Fuminori Muranaga
1Department of Medical Informatics, Graduate School of Medical and Dental Sciences, Kagoshima University.
Studies in Health Technology and Informatics
|August 8, 2013
Summary
A new electronic patient record system, the "e-kanja recording system," allows all medical staff to share identical patient information. This system improves record quality through shared access and peer review, aligning with Japan
Area of Science:
- Medical Informatics
- Clinical Documentation Systems
Background:
- Problem-Oriented System (POS) is recommended in Japanese clinical guidelines, often utilizing the SOAP note format.
- Existing systems may present challenges in standardizing clinical information entry across different healthcare professionals and patient types (outpatient/inpatient).
Purpose of the Study:
- To develop and implement an electronic patient record system facilitating unified clinical information entry.
- To enable chronological observation and sharing of patient data among all healthcare team members.
- To enhance the quality of clinical records through a peer review mechanism.
Main Methods:
- Development of the "e-kanja recording system" with a focus on standardized data entry.
- Implementation across various healthcare professions, including doctors.
- Integration of features for chronological data review and inter-professional access.
Main Results:
- Successful creation of a unified electronic patient record accessible to all staff.
- Facilitation of information sharing among multidisciplinary teams.
- Demonstrated improvement in record quality attributed to shared access and peer evaluation.
Conclusions:
- The "e-kanja recording system" effectively standardizes clinical information entry and sharing.
- The system enhances medical record quality by enabling collaborative review.
- This approach supports adherence to clinical guidelines recommending structured record-keeping.
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