• Title/Summary/Keyword: 병원기록

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A Study on the Current Status and Tasks of Medical Records Management: Focused on Applying the KS X ISO 15489 to the Y Hospital (의무기록관리의 현황과 개선방안: KS X ISO 15489표준의 Y병원 적용 중심으로)

  • Lee, Eun-Mi;Kim, Myeong;Hee, Jin
    • Journal of the Korean Society for information Management
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    • v.29 no.3
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    • pp.257-285
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    • 2012
  • As the electronic medical records systems (EMRs) are introduced into the hospitals in Korea and the needs of chief stakehoders of medical records are changed, the environments related to creating and managing medical records has been changed dynamically. At this moment it might be meaningful to examine medical records based on records management principles rather than information management principles. The purpose of this paper is to apply the KS X ISO 1549 standards, which covers the principles of records management, to hospital medical records management and assess the current quality of medical records management, and define a few tasks of improvement for hospitals. To achieve this goal, this study has performed following activities: Firstly, principles that could be applied to medical records management were prepared for each record management steps described in the standards, such as capture, registration, classification, storage, access, trace and disposition, and 22 principles were selected from those 7 steps of the record management. Secondly, the Y hospital, which is affiliated with a medical school in Seoul, was chosen to evaluate the current situation regarding medical records management. The department head of the medical records management team in Y hospital was interviewed and the present status was evaluated according to each principle. Thirdly, tasks for improvement were suggested, in such stages as access, trace and disposition. With this study as a cornerstone, useful implications are expected to be gathered from future studies that apply standards for metadata of records, management systems for records, and record management systems to medical record management in hospitals.

Hospital Integrated Computerization System (병원 통합 전산화 시스템)

  • Kim, Jin-Ok;Jun, Tae-Ryong;Shin, Tae-Sung;Lho, Young-Uhg;Kim, Kwang-Baek
    • Proceedings of the Korean Institute of Information and Commucation Sciences Conference
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    • v.9 no.2
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    • pp.1132-1134
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    • 2005
  • 현재의 병원 전산 시스템은 각 병원의 자체 전산화 구축으로 인하여 각 개인의 진료기록 및 처방전 등 개인의 신상 자료가 한 병원에 국한되어 있고 타 병원 및 공공기관에서의 진료기록 필요시 진단서를 발급해야 하는 불편함이 초래하고 있다. 이에 본 논문에서는 개인의 신상 기록 및 진료기록 통합 시스템을 제안한다. 제안된 방법은 통합데이터베이스 서버를 구축하고 각 병원 및 약국에서는 전용선을 통하여 접속함으로서 개인의 진료기록 및 처방전을 각 병원과 약국에서 공유할수 있게 되어 병원관리의 투명성과 신뢰성이 제고된다.

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A Development of XML Converter for Electronic Medical Record (전자의무기록용 XML Converter 개발)

  • 김승석;이상준;김병기
    • Proceedings of the KAIS Fall Conference
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    • 2001.05a
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    • pp.378-382
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    • 2001
  • 최근 의료계에서는 의무기록을 전자문서화 하는 연구가 활발히 진행되고 있다. 더불어 전자의무기록의 표준화에 대한 노력도 병행되고 있으며, XML이 이에 대한 대안 중 하나로 제시되고 있다. 이에 따라 기존 병원 정보시스템에 구축된 의료정보를 XML로 변환하는 방법에 대한 연구가 요구된다. 본 논문에서는 간략화한 의무기록을 XML로 표현하는데 필요한 DTD를 제안하며, Java 프로그래밍 언어를 이용하여 기존 병원의 Legacy Database에 기록된 의무기록 자료를 XML 문서로 변환하고, 전자의무기록 XML 문서를 병원정보시스템에서 활용할 수 있도록 Database에 기록하는 Converter를 구현하였다.

A Study on the Analysis and Methods to Improve the Medical Records Management in a Large University Hospital (대형 대학병원의 의무기록관리 현황분석 및 개선방안에 관한 연구)

  • Lee, Ju-Yeon;Kim, Yong;Kim, Geon
    • Journal of Korean Society of Archives and Records Management
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    • v.13 no.1
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    • pp.107-134
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    • 2013
  • Many hospitals introduce the electronic medical record systems (EMRS) to implement a digital type of hospital. However, there are various problems in managing and preserving medical records. Systems, such as OCS, PACS, and EMR, are independently operated without formal standards related to medical records management. To manage medical records effectively, distributed medical records including paperand electronic-type should be managed in an integrated manner. With its analysis of the current status in the management of medical records of J University Hospital, this study proposes methods to solve the problems extracted from the results of the analysis, and a management model for an integrated medical records management based on the process of records management of ISO 15489.

Over-the-counter drug records and management (일반의약품 기록 및 관리)

  • Gang, Yoo-ha;Kim, Ji-Yun;Yun, A-eun;Song, Tae-Yeong;Choi, Young
    • Proceedings of the Korean Society of Computer Information Conference
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    • 2021.07a
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    • pp.347-349
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    • 2021
  • 전문의약품은 의약품안전사용서비스(DUR)를 이용하여 병원에서 처방받은 약에서 부작용이 나타났을 때 기록하고 다음에 약을 처방받을 때 부작용이 나타난 약과 비슷한 계열의 약은 처방받지 않는다. 하지만 일반의약품은 약 구매 기록조차 남지 않아 어떤 약을 언제 처방받았는지 모르고 부작용을 관리할 수 없어 불편함을 겪는다. 이 연구를 통해 제안하는 어플은 처방내역과 복약관리, 약 추천, 약국 찾기로 구성된다. 일반의약품을 처방받은 날짜와 시간, 증상, 효과, 부작용에 대하여 기록하며, 기록을 분석하여 증상에 대한 약을 추천함으로써 치료 효과를 높일 수 있다. 환자가 스스로 투약에 관심을 가지고 기록을 관리함으로써 환자가 주체가 되어 질병을 개선할 수 있다.

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Electronic medical record system using QR code (QR코드를 활용한 전자의무기록 시스템)

  • Ji Ho Park;Deok Gyu Lee
    • Proceedings of the Korea Information Processing Society Conference
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    • 2023.05a
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    • pp.328-329
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    • 2023
  • 현재의 전자의무기록 시스템은 타 병원에서 진료를 볼 때, 중복 검사를 피하기 위해서는 기존 병원에서 검사 또는 진료 기록을 받아 제출해야 하는 번거로움이 있다. 이에 본 논문에서는 기존 시스템의 클라우드화를 통해 타 병원 진료 시 비용과 시간 단축이 예상되며, QR코드를 주민등록증 대신 사용하여서 주민등록번호 노출과 주민등록증 위변조를 통한 불법적인 활용이 불가하다고 생각한다.

Hospital Workers' Awareness and Attitude Towards Medical Records and OpenNotes (진료기록과 오픈노트(Open Notes)에 대한 병원 종사자들의 인식과 태도)

  • Choi, Ju-Hee;Seol, Hee Yun;Kim, Sung-Soo
    • The Journal of the Korea Contents Association
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    • v.20 no.12
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    • pp.635-645
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    • 2020
  • An "OpenNote" can be defined as the sharing of medical records between patient and doctors by online, and is a new trial to allow patients to access their medical records any time. To identify the need for the introduction of OpenNotes, which is expanding medical recrods, this study has researched the awareness and attitude towards medical records and OpenNotes among hospital workers in charge of part of medical servises. One of the results in this study is that recognizing his or her own records can impact his or her understanding his or her health status. Also, the subjects who were participated in this study generally agreed with the usefulness of the OpenNote and were willing to participate in the OpenNote. Meanwhile the subjects are admitting counterfeiting the medical records or falsifying them. The conclusion has been shown that patient-doctor sharing of medical records could help patients better understand their health information and encourage their self-care. When patients can access their own medical records easily, Unnecessary misunderstandings and distrust of records between patients and medical staff can be markedly reduced then it can help to build up the trust in a doctor-patient relationship. Considering not only the health utility of OpenNotes but also the impact on the trust of doctors, the pilot project of OpneNotes for experimental verification is proposed.

A Study on Reliable Electronic Medical Record Systems (신뢰할 수 있는 전자의무기록에 관한 연구)

  • Kim, Yong-Young;Shin, Seung-Soo
    • Journal of Digital Convergence
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    • v.10 no.2
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    • pp.193-200
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    • 2012
  • The existing EMR method placing computer servers in hospitals could expose patients' personal information to hospital officers and people for wrong purposes. In addition, if medical malpractice occurs, the possibility of distorting medical records might be higher because patients' medical records are stored in hospitals. This study provides an electronic medical record with a security system to solve patients' information disclosure. The electronic medical record system could be utilized as an important information when medical malpractice occurs. This system can provide higher security services certifying patients safely and efficiently as well as protecting patients' personal information.