紹介報告書・退院時サマリー使用状況の実態調査

A survey of the use of patient reports and discharge summaries

要旨：富山県作業療法士会に所属している作業療法士を対象に，紹介報告書・退院時サマリーに関する実態調査を実施した．患者転院時の紹介報告書添付を83％の人が業務の一環と認めていた．しかし，紹介報告書の使用率は4割未満であった．紹介報告書を作成しない理由が種々あげられ，それらの理由に身障，老人，小児，精神の各分野で違いが見られた．紹介報告書に関する知識や記載方法について，今まで殆ど習得する機会がなく，勉強会や研修会を希望している人が多く見られた．現状の病院・施設間情報交換のあり方に問題を感じている人が75％見られ，問題点や改善策について具体的な意見があげられた．今後，医療機関の有機的な連携や情報交換を推進するには，各病院・施設，都道府県作業療法士会，日本作業療法士協会等で情報交換システムの構築に取り組む必要性が示唆された．

　Recently, many patients have been transfering from several rehabilitative facilities until the termination of their rehabilitative services is reached.

　In such situations, exchanges of patient records are increasing, which means that we occupational therapists should develop good methods of transferring patient information. However, little is known about how information is exchanged and what occupational therapy practitioners require in transfer records.

　Therefore, we investigated patient records and discharge summaries used in the exchange of information and the opinions of occupational therapy practitioners in the Association of Occupational Therapist of Toyama Prefecture.

　The collection rate of the questionnaire was 77%. 83% of the members recognized that exchanging information is an important duty. However, many members did not use transfer reports. We found that there were many reasons for this, and, in addition, there were different conceptions about needs for information disclosure in different treatment fields.

　Most of the members have not compiled discharge summaries on a usual basis, and no formal record forms are used.

　Many members reported that they had never learned the skills of medical documentation, but they wished to have the opportunity to do so.

　We found that most of the occupational therapy practitioners are not satisfied with the present information exchange situation.

　In this study, we presented the problems and proposed that an information exchange system for occupational therapy should be established.