電子カルテ導入とペーパーレス運用化

Installation of electronic medical recording system and paperless operation

要約　目的：病院に導入した電子カルテシステムによる眼科運営の報告。方法：病床300床の病院に，1年前の新築移転を機に電子カルテシステムを導入し，すべての部署で紙とフィルムを使わないことにした。眼科にはこれと接続する眼科用サブシテムを開発して機能を分担させ，円滑な入力と閲覧環境を構築した。結果：眼科でも紙とフィルムを使わずに運用が実現された。導入前に比べ，予約がある再診患者では診察に要する時間は短縮し，予約がない再診患者と新患については診察に要する時間が延長した。結論：電子カルテシステムを導入することで，事務手続きが軽減し，診療録が読みやすくなり，院内の他部署での閲覧が容易になった。これにより情報が共有できチーム医療が推進された。

Abstract.　Purpose：To report the current status of eyecare after installation of electronic medical recording system and paperless operation. Method：An electronic medical recording system was installed in a hospital which has 300 beds and which was rebuilt one year ago. This system was intended to eliminate use of paper and film material in all departments. A subsystem was designed to be used by ophthalmological department to facilitate easy input and data retrieval. Results：Use of paper and film material was entirely eliminated in the department of ophthalmology. When compared before installation of the system,patients spent less time for consultation or examination. Patients without appointment including new patients spent more time for consultation. Conclusion：Installation of electronic medical recording system resulted in less paperwork in the office,in better legibility of medical records,and in sharing information with other departments. These features facilitated better medical care as a team.