山梨大学看護学会誌　第4巻1号　027-033(2005)

＜原著＞
通所サービス提供者と利用者家族間における
連絡ノートの形式と記載実態

新田 静江，望月 紀子，清水 祐子，上村 奈美

通所サービス提供者と利用者家族間で使用されている連絡ノートの形式と記載実態を明らかにすることを目的に，通所サービスと訪問看護の併用利用者50事例の過去1か月分の連絡ノートの複写をデータとした。その結果31か所の通所サービスで27種の形式があり，家族が記載する項目，通所サービス提供者が記載する項目と自由記載欄があり他サービス提供者記載欄のないものが最多であった。大半の通所サービス提供者はバイタルサイン・日常生活動作項目と状態・生活状況を，一部家族が日常生活動作項目とお礼と生活状況を記載しており，サービス利用回数・期間と家族記載率に関連はみられなかった。この調査から，通所サービス事業者が独自形式のノートを用い他サービス提供者との連携には活用していない実態があった。今後は連絡ノートを情報交換に活用し得る形式，家族支援に活用できる記載能力の習得，サービス計画の検討資料としての活用等が課題であろう。

キーワード:通所サービス，高齢者，家族，連絡ノート



Forms and Contents of Notebooks Utilized Between Elderly/families and
Day-Service Providers

NITTA Shizue, MOCHIZUKI Noriko, SHIMIZU Yuko, UEMURA Nami

　The purpose of this study was to examine the forms and contents of notebooks utilized between elderly/families and day-service providers. The subjects included 50 elderly receiving both day-services and home-health nursing. The data used were photo copies of notebooks written in the past month. At 31 day service agencies, 27 forms of notebooks were utilized. The majority of notes contained closed-ended items and unstructured reports for day-service providers and elderly/family, but not for other service providers. Most families checked items about ADL and wrote their appreciations as well as the general condition and living situation of the elderly at home. Most day-service providers checked items of VS and ADL, and described the general condition and interaction of the elderly during day-services. ANOVA revealed no significant relation between the frequency or length of day-services and the frequency of documentations written by the families. These findings indicate that the forms of notebooks used by day-service agencies vary widely and these agencies utilize them for providing information to the elderly/families, but not for providing or exchanging information among service providers for home health. The study suggests the need to develop a handy notebook to exchange information among the elderly/families and agencies, to educate care providers in order to acquire to the skills necessary for effective documentation, and to use the contents of notebooks as assessment data for a care plan.

keywords: Day-service, Elderly, Family, Notebook


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