Quality improvement in the community-health-care cooperation through the application of the “My Diagnosis & Treatment Record”

Abstract

This study researches the use and practical application of the “My Diagnosis & Treatment Record” currently implemented at the Kagawa Rosai Hospital. The “My Diagnosis & Treatment Record” is a file for gathering a patient's own drug and care information. The contents of the information are various data, such as a hospitalization, treatment planning document, a disease and a treatment description, various consent documents, an overview critical path of inter-regional association, a critical path for patients, a nursing care plan, an inspection result, medication counseling, the care plan of the elderly care insurance, records of being home, and the drugs information from a dispensing pharmacy, etc. It is currently used for diagnosis of cerebral apoplexy and femoral neck fracture, and is mostly useful now as an “information shared file” between the medical staff of an acute stage, convalescence and maintenance term and being home. Further use also in cancer community-health-care cooperation is desirable.