精神科外来における病名記載の実態に関する検討

概要

論文の詳細を見る
The psychiatric diagnosis recorded in documents is often inconsistent with that in the medical record. The object of this study was, by comparing the true diagnoses and those recorded in documents, to investigate the issue of how the diagnosis is presented to the patient and how the psychiatric diagnosis may influence the patient and society. We examined the documents in the medical records of 2350 psychiatric outpatients at the psychiatric department of Shinshu University Hospital from December, 1998 to May, 2005.We classified the documents as public or private. The public documents are those submitted to public organizations, such as application forms for a handicapped pension. The private documents are those submitted to schools, offices, insurance companies, etc. such as hospitalization certificates. Patients with depression were mostly recorded as “depression” or “depressive state” in both public and private documents. Patients with schizophrenia usually were recorded as schizophrenia in public documents and “neurosis”, “neurasthenia”, “autonomic disorder”, or “depressive states” in private documents. Hesitation about telling the true diagnosis to the patient, and the influence of the written diagnosis upon the society around the patient may have contributed to the discrepancies between the true diagnoses and the recorded diagnoses in private documents.6
信州医学会の論文