[2-E-2-01] 退院サマリー標準化の意義 ～退院サマリーから何を主要PPIとして抽出するか～
（退院時要約等の診療記録に関する標準化推進合同委員会より）
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.
Since 2014, the Joint Committee for the Standardization of Discharge Summary has been working for making a standard architecture of the discharge summary and submitted the form “the Discharge Summary Standard based on HL7 CDA” to the HELICS Council in 2018, which was successfully approved in Jun 2019.
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, 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.
From the viewpoint of patient-centered utilization of the discharge summary, “Problem List”, “Allergy and Adverse Reaction”, “Drugs used at discharge”, and if present, “Device” are thought to be important and valuable items, especially when you think of the formation of personal health records (PHR).
Since 2014, the Joint Committee for the Standardization of Discharge Summary has been working for making a standard architecture of the discharge summary and submitted the form “the Discharge Summary Standard based on HL7 CDA” to the HELICS Council in 2018, which was successfully approved in Jun 2019.
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, 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.
From the viewpoint of patient-centered utilization of the discharge summary, “Problem List”, “Allergy and Adverse Reaction”, “Drugs used at discharge”, and if present, “Device” are thought to be important and valuable items, especially when you think of the formation of personal health records (PHR).