Analysis and Categorization for the Standardization of Medical Referral Document Information

As a response to the rise in the number of elderly persons, Japan’s Ministry of Health, Labour and Welfare is promoting the creation of community-based integrated care systems and regional medical care concepts. In order to do this effectively, the ability to share information among medical facilities will be critical. A common method of sharing information between medical facilities is through the use of patient referral documents ( Form 11 ) . In the present study, in order to standardize information sharing for secondary applications other than referrals, the contents of 1,000 patient referral documents were analyzed and categorized. As a result, data specifying reasons for referral were structured into 4 layers, from which 18 categories were derived. Data from the medical history section were sorted into 8 categories and 33 subcategories. These findings will be useful when creating a medical information sharing system compliant with Form 11.