| 摘要 |
<P>PROBLEM TO BE SOLVED: To provide an assessment file as a medical treatment record format realizing a new data abstracting function by gathering data of recorded contents based on data of medical treatment, standardization for nursing care record items, and quantitative determination of recording methods, which are not included in conventional electronic medical records, nursing care support apparatus or clinical passes. <P>SOLUTION: An assessment sheet 1 is provided with an outcome 3 which is provided for a name of a disease and every progressed day after a medical operation and is all target goals of symptoms and conditions of a disease for a patient given cares for the disease, and an assessment 2 as indexes which become criteria of assessment for achieved rates of all target goals at a progressed date. Further, the assessment file is formed by collecting assessment classes for each disease, which are formed by collecting all the assessment sheet 1 for each disease during all progressed days. Thus, gathering data of the recorded contents is carried out by standardization of record items and quantitative determination of recording methods, and recorded data are integrally shared with medical staffs of all categories including medical doctors. Consequently, nursing care records are evaluated as data having great value of information. <P>COPYRIGHT: (C)2004,JPO |
