回復期リハビリテーション病棟における電子カルテの実態調査

Survey of the Electronic Medical Recoding System Used in Kaifukuki Rehabilitation Wards

要旨：日本リハビリテーション医学会専門医会によって設立された「リハ医療に必要な電子カルテ機能を検討するワーキンググループ」は「電子カルテ機能評価：回復期リハ病棟版」を作成し，その機能評価を用いて回復期リハ病棟における電子カルテの実態調査を行った．方法：電子カルテを導入している回復期リハ病棟を有する 153施設を対象として，郵送法によるアンケート形式の調査を行った．調査では電子カルテ機能評価（回リハ病棟版）の自己採点結果，電子カルテの使用期間・満足度を尋ねた．結果：有効回答率は53.6％（82施設）．電子カルテ機能評価の総合点中央値は60.5点．項目別にみると全項目で1～5点までのばらつきが認められた．結語：回復期リハ病棟に導入されている電子カルテは，リハ医療特有のニーズに十分に対応しきれておらず，施設によって相当の差があることも判明した．

Abstract : A working group, established by the Japanese Board-certified Physiatrist Association to examine the necessary functions for an electronic medical record keeping system for rehabilitation, created a functional evaluation system for electronic medical record keeping in kaifukuki rehabilitation wards. The group conducted a survey to determine how electronic medical records are actually being used in kaifukuki rehabilitation wards. Methods : The group sent questionnaires to 153 hospitals with kaifukuki rehabilitation wards by mail. The questions included the period of usage, how satisfied they were with their system, and a self-evaluation form for their electronic medical record functional evaluation. They asked the respondents to evaluate each item from 1 to 5 points. Results : The group received answers from 82 institutions, with a valid answer rate of 53.6％ in total. The median of the electronic record functional evaluation was 60.5 points. The points given varied from 1 to 5 in all items. Conclusion : It was determined that electronic medical records are equipped with a minimum of functions for rehabilitation, but also that there are great functional differences among institutions.