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160120 三重大「論理的カルテ」配布資料
160120 三重大「論理的カルテ」配布資料
6935211
MMC
415
151
185
14
416
194
50
80
dr.kenta.sato@gmail.com
14
104
55
199 2
1073044
76%
10%
0.6%
HP http://www.min-iren.gr.jp/ikei-gakusei/igakusei/zi5_medi/2011/049/mw-ken-49.html
HP http://www.chidoribashi-hp.or.jp/chidoribashi-hph/index.html
2016/1/19
Common Disease
2
4
Common disease
Common disease
TOP50
400
150
150
150
16
12
3
12
WebSNS
NPO
ICTIT
IT
etc.
Google
https://www.igaku-shoin.co.jp/paperDetail.do?id=PA02985_05
2016/1/19
SOAP
NEJMCRPData
NEJMWarrant
CRPClaim
DataWarrant
NEJM
DataWarrant
CRP
https://kogolearn.wordpress.com/studyskill/chap4/sec2/
Claim
Data/Warrant
Evidence based medicine !?
Data
EBM
Warrant
Data
Warrant
EBM
http://spell.umin.jp/EBM.htm
Claim
Subjective
A
Plan
Objective
2016/1/19
SOAP
AP
SOAP
SO
AP
Amazon
POSSO
DataWarrant
2016/1/19
3
O
etc
Subjective
(OPQRST)
Review of Systems
EBM
or
http://spell.umin.jp/EBM.htm
ADL
2016/1/19
Objective
General appearance
First impressionABCD
Vital signs
Head to Toe
General appearance
Ns
GoodSosoBad
BMJ
https://www.facebook.com/journalofI/posts/287005368067429
https://www.jstage.jst.go.jp/article/generalist/35/4/35_299/_article/-char/ja/
General appearance
JCS0BP9456PR96RR26SpO2 92%R/ABT36.8
S3(+)(-)
(-)(-)(-)
(+)
BUN20.1Cr1.23T
PVCHR90V1-4ST
XpCTR55
Pertinent
Pertinent positive
Pertinent negative
Non-pertinent positive
Non-pertinent negative
Jolt
Kernig
Non-pertinent
Pertinent negative
2016/1/19
Brief summary
Assessment
Brief summary
Opening statement
SO
SOData
STT
Warrant
Pertinent
30
#1ACS
Brief summary
30
Definite
Less likely
AHASTEMI
#2
ACS
ACS
STEMI(2013)
SOAP
SO
AP
2016/1/19
Assessment
Plan
52319
Plan
Tx
Dx
Ex
PCI
Tx20mg550mL4mL/
100mg275mg4
Dx
ECGSpO25
Ex
Px
SOAP
CVA
IE
UpToDate
Fever work-up
MRI
PxACE
SO
ASODataWarrant
Claim
P
2016/1/19
SOAP
Simple
11
Comprex
Complicated
60
AKI
RADM
Chaotic
70
MaintenanceCrisis
40
DMDLNAFLDHCV
30
Simple
Complicated
By ploblem
Complex
Chaotic
SOAP
SOAP
2016/1/19
Complicated
0
1
#1.
2
Semantic qualifier : SQ
#2.
#3.
4
58
SO
Semantic Qualifier
10
2016/1/19
#1. 14.4.20
MCV7014.4.20SQ)
514.4.22SQ)
CF14.4.26
14.4.30
cStageT3N2M114.5.3
PS4PPS14.8.24
#1.
SQ)
#1.100Nohria4
#2.
#1
Simple is BEST!!
#1. ACS#2.
#2. #3.
#4. #5. #6.
#7. #8.
#9. #10 . #11.
A
SO
A#1. ACS
P
S
A#1. ACS
#2.
#3.
P
# # #1.#a.
#1. #2. #3.
#a. #b. #c.
11
2016/1/19
Complex
OA
OA
Complex/moderateFrailOrgan13282
OA
CHF(HFrEFAHA stage2)
LDL
AUDIT
ACP
ACP
Brief title
Opning statement
Complex / hardFrail + CVD13
12
2016/1/19
RIME
Kolb
Reporter()
SO
Interpreter()
SOA
Manager()
AP
Educater()
13
2016/1/19
Frequent
Accurate
Specific
Timely
12
http://www.igaku-shoin.co.jp/paperDetail.do?id=PA02985_05
HP
http://www.nanzando.com/journals/chiryo/
14