みなさん、病院にかかった時にカルテにどんなことを書かれているか知りたいと思いますか？
最近では、カルテ開示を求める市民の会なるものまでありますね。 でもですね、個人的な意見を言わせて貰いますと。 読めませんよ、カルテ。 字が汚くて。 手書きだと。 電子カルテなどではパソコンで入力されているのでそんな事は無いんでしょうが、外科部長の鶴の一声で手書きのままです。 医療ミスを減らすためにも、手書きの場合では誰でも読める字、もしくはパソコン入力されている電子カルテなんかは必須ですよね。 今後は業務の円滑化をはかる上でも全て電子カルテになるでしょう。 しかし、個人情報保護法の絡みでコメディカル（看護師、臨床検査技師、診療放射線技師、臨床工学技士、管理栄養士、理学療法士、作業療法士、社会福祉士、視能訓練士、言語聴覚士など）にはカルテが手元に届かず、検査のオーダーだけが自分の元に届くなんて実際に病院も存在します。 これでは、オーダーミスを確認する手段がありません。 さて、話を戻します。 僕が、仕事を始めたばかりのころは専門用語がわからないのに加え、諸先生方の曲字が読めなくて苦労しました。 とっても可愛らしい、幼稚園生の女の子がいました。 女の子「○○幼稚園のユリ組の○○です！！」 元気一杯に、可愛らしい自己紹介をしてもらいました。 僕「○○ちゃんはユリ組なんだー、ちょっと待っててね。」 検査をする前にカルテを確認。 字が汚くて読めない。 なんとか解読してみる。 うーん、なんて書いてあるんだろう。 えーと、顔かな？ 顔・・・が。 か・・・わ・・・い・・・い。 ？？？？？ 顔が可愛い？ いやいや、カルテにそんな事が書いてるわけないな。 いや、でも、『顔が可愛い』 以外に読めない。 この子、確かに可愛い。 喋り方も可愛らしいし、将来は美人になりそう。 で、でも、カルテにそんな関係ない事は書くわけないよな。 先輩に相談してみる。 僕 「すみません、ちょっとカルテでよくわからないところがあるので見ていただきたいんですが。」 先輩「あー、わかった、見せて。」 先輩「うーん・・・とね、顔が可愛いって書いてあるね。」 耳を疑う。 僕 「顔が可愛いですか？」 先輩「そうだね、顔が可愛いって書いてあるよ。」 僕 「あのー、カルテってそういうことも書いてあるもんなんですか？」 先輩「この先生お茶目なところがあるからねー。」 お、お茶目？ それでいいの？ この先生腕は確かです、間違いなく。 でも患者さんを目の前にして、お茶目な一言メモを読みたいなんて気持ちはこれっぽっちもないんですけど。 仮に、カルテに一発ギャグなんて書かれていた日には患者さんの目の前でカルテを読みながら笑っちゃうかもしれない。 僕 「クククッ。」 患者「どうしたんですか？」 僕 「いや、何でもないです。」 患者「じゃあ、なんで笑ってたんですか？」 僕 「いやね、カルテに書いてあったギャグが面白くて。」 意味がわからない。 お互いに。 カルテってそんなことも書いてあるんだなーっと当初はちょっとだけ思いましたが、後にも先にもこんなことを書くドクターはこの人のみでした。  ↑参加中のブログランキング。  ↑クリックするだけで、 無料で募金ができます。   |
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むむ・・ プロなお仕事にお茶目な一言。 実力に裏打ちされた心の余裕が感じられますな。 そーいうプロな男になりたいもんです。 カルテって･･･ 医師ごとに解読コードが必要なくらいですよね
【2005/12/31 12:57】
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【2006/01/01 00:32】
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BIG Tさん＞ 周りからプロと呼ばれたいです、僕。 小包さん＞ そうですね、医師ごとに違いますね。 ａｚｕｄａｓｕさん＞ こちらこそよろしくお願いします。 ももいろうさぎさん＞ 来年もがんばってブログを書き続けます。
【2006/01/01 02:09】
URL | ピーター･クリンチ #-[ 編集]
私は皮膚科にかかってますが、確かに字読めませんね。日本語・・・じゃないんですか？あれって。 英語と、日本語と、ドイツ語を混ぜ混ぜで書いてますね。 若いドクターなんかは、英語の人がわりと多いです。
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