[2-D-1-01] 医療情報学会・診療情報管理学会 合同企画ワークショップ ～標準化される退院時要約（退院サマリー）
The Joint Committee for the Standardization of Discharge Summary submitted the form “the Discharge Summary Standard based on HL7 CDA” to the HELICS Council in 2018, which was successfully approved in Jun 2019.
The discharge summary is an important concise document for the information sharing among the acute-phase hospitals, where precise and exquisite examinations and diagnoses are made, and also where interventions which significantly affect patients’ health status are performed, and the local community healthcare facilities.
Most importantly, a discharge summary is not a short memorandum of in-hospital period, but a complex of summarized significant past health problem lists plus additional information about the diagnoses and interventions in particular inpatient healthcare period, which should be conveyed as a concise file.
In standardization process, minimally required items are determined, along the line recommended by various international accreditation organizations, and at the same time the architecture is set so that the necessary items are automatically funneled into from corresponding formats in the electrical medical record in order to facilitate and expedite the summary making. (Addition of necessary items for a particular institution is also possible by utilizing CDA architecture.)
Items of the standardized summary are: 1. basic information 2. problem list at discharge 3. allergy & adverse reaction (4. device) 5. Reason for admission 6. preadmission information 7. in-hospital course (8. intervention) 9. condition at discharge 10. medication at discharge 11. follow up plan.
From the viewpoint of patient-centered utilization of the discharge summary, 2, 3, (8), and 10 are thought to be important and valuable items, especially when you think of the formation of personal health records (PHR).
The discharge summary is an important concise document for the information sharing among the acute-phase hospitals, where precise and exquisite examinations and diagnoses are made, and also where interventions which significantly affect patients’ health status are performed, and the local community healthcare facilities.
Most importantly, a discharge summary is not a short memorandum of in-hospital period, but a complex of summarized significant past health problem lists plus additional information about the diagnoses and interventions in particular inpatient healthcare period, which should be conveyed as a concise file.
In standardization process, minimally required items are determined, along the line recommended by various international accreditation organizations, and at the same time the architecture is set so that the necessary items are automatically funneled into from corresponding formats in the electrical medical record in order to facilitate and expedite the summary making. (Addition of necessary items for a particular institution is also possible by utilizing CDA architecture.)
Items of the standardized summary are: 1. basic information 2. problem list at discharge 3. allergy & adverse reaction (4. device) 5. Reason for admission 6. preadmission information 7. in-hospital course (8. intervention) 9. condition at discharge 10. medication at discharge 11. follow up plan.
From the viewpoint of patient-centered utilization of the discharge summary, 2, 3, (8), and 10 are thought to be important and valuable items, especially when you think of the formation of personal health records (PHR).