• Title/Summary/Keyword: 의무기록분석

Search Result 701, Processing Time 0.026 seconds

Clinical Contents Model to Ensure Semantic Interoperability of Clinical Information (의료정보의 의미적 상호운용성 보장을 위한 임상콘텐츠 모델)

  • Ahn, Sun-Ju;Kim, Yoon;Yun, Ji-Hyun;Ryu, Sang-Hee;Cho, Kyoung-Hee;Kim, Seong-Woo;Kim, Seung-Soo;Kwak, Mi-Sook;Yu, Seung-Jong;Koh, Young-Taeg;Choi, Duck-Joo
    • Journal of KIISE:Software and Applications
    • /
    • v.37 no.12
    • /
    • pp.871-881
    • /
    • 2010
  • Objective: A clinical contents model is an essential data model to exchange clinical data, among existing computer systems and enhance consistency of necessary data, in terms of its meaning and reusability. However, there has not been a domestic case where such clinical model is developed till present. Methods and Results: This research is based on determining principles of developing clinical information model which is a specified model of Health level 7 Reference Information Model and attempts to identify clinical contents with types of ENTITY-ATTRIBUTE-VALUE, based on terminology standard by clinicians and domain modelers. Conclusion: This model is projected to be utilized in the next generation of EMR as core contents.

A Study on the Data Warehousing System of General Hospital (종합병원 데이터웨어하우스 시스템에 관한 연구)

  • 박찬석;고석하
    • Proceedings of the Korea Society for Industrial Systems Conference
    • /
    • 2002.11a
    • /
    • pp.304-318
    • /
    • 2002
  • 본 연구는 종합병원에서 운영중인 병원정보시스템(Hospital Information System)을 기준으로 업무별 데이터 마트를 구성하여 종합병원 데이터 웨어하우스 시스템을 제안하는 연구이다. 본 연구에서 제안한 병원 데이터웨어하우스 모형은 충남대학교병원 데이터 웨어하우스 시스템 구축 보고서, Inmon의 데이터 웨어하우스 개발방법론에 기초를 두었다. 종합병원의 데이터하우스시스템을 제안하면 다음과 같다. 첫째, 원무 데이터마트, 병원의 원무팀에서 주로 사용하는 것으로써 수입에 관련된 정보, 진료인원에 관한 정보, 심사/청구/삭감에 관한 정보들로 구성되어 있다. 둘째, 약국 데이터마트, 처방전달 데이터 마트와 연결되어 외래/입원의 처방에 관한 정보, 약에 대한 효능과 성분에 대한 정보, 투약과 검사에 대한 정보들로 구성된다. 셋째, 의무기록 데이터마트, 의무기록팀에서 관리하는 퇴원요약 정보, 암환자에 대한 정보, 외래/입원 환자 통계에 대한 정보들로 이루어진다. 넷째, 처방전달 데이터마트, 주로 의사가 환자에게 행한 처치/처방/수술과 진료기록에 대한 정보들을 기준으로 환자진료나 임상연구에 필요한 정보를 제공한다. 다섯째, 병원 행정 데이터마트, 인사정보, 급여정보, 회계정보, 예산정보, 물류정보 등으로 구성되어 병원의 자원활용이나 행정에 대한 전반적인 정보를 제공한다. 여섯째, 경영지원 데이터마트, 병원경영에 필요한 수입정보, 원가분석 정보, 진료인원 정보들을 요약한 형태로 제공한다. 또한 의사결정 형태도 의료진 중심의 병원에서 환자중심의 병원으로 구조를 바꾸었고 투명한 정보공유와 기초 데이터들의 정제는 부가가치가 높은 정보로 가공할 수 있게 되었으며 각 전문 직종간의 단절된 정보 흐름을 유기적으로 교환할 수 있게 되어 지식의 교환을 촉진시켰다 그리고 온라인거래처리시스템(OLTP)의 한계점인 하드웨어적인 문제와 성능 저하에 대한 문제를 해결하였고, OLTP시스템에서 분리되고 이원화된 코드체계와 데이터 형태의 이질화를 통일하는 방법으로 데이터웨어하우스 시스템을 제시하였다. 결국 병원에서 데이터웨어하우스 시스템의 구축은 임상, 연구, 교육의 유기적 순환관계를 정립하여 지식의 순환적 고리인 수집, 공유, 확산, 재창출을 지속적 유지할 수 있는 인프라를 구축해 준다. 반면 상이한 정보들간의 충돌과 이에 따른 해석의 오류로 잘못된 의사결정을 위한 정보를 제공할 수 있고 기초정보의 접근 및 추출의 유용성에 의해서 정보유출에 대한 문제가 한계점으로 나타났다.

  • PDF

Analysis of Pain Records Using Electronic Nursing Records of Hospitalized Patients in Medical Units at a University Hospital (일개 대학병원 내과 병동 입원환자의 전자의무기록에 사용된 통증간호 기록 분석)

  • Park, Ihn Sook;Jang, Mi;Rew, Soon Ae;Kim, Hee Jin;Oh, Phil Joo;Jung, Hee Jung
    • Journal of Korean Clinical Nursing Research
    • /
    • v.16 no.3
    • /
    • pp.123-132
    • /
    • 2010
  • Purpose: This study was done to analyse nursing records to identify the nature of pain and actual conditions of pain management in patients hospitalized in one university hospital. Methods: The participants in this study were 783 patients with a length of stay of 3 to 30 days who were discharged from medical wards between June 1 and June 30, 2009. Data on nursing records related to pain management from these patients were reviewed using the Electronic Nursing Records (ENRs) system. Results: Over 30 percent of 10,702 nursing records related to pain assessment had no record on region, severity, nature or frequency of pain. About 30 percent of 13,638 nursing records related to pain intervention showed non-drug pain management techniques. Conclusion: Accurate and complete records on pain assessment including region, severity, nature and frequency of pain are essential to effectively manage patients' pain. Improvement in ENRs system for better assessment and management of pain is required as well as education programs on a standardized measuring tool for both nurses and patients.

Short-Term Impact Analysis of DTG Installation for Commercial Vehicles (사업용 자동차의 DTG 설치 단기 효과분석)

  • Lee, Seok-June;Lee, Chungwon
    • The Journal of The Korea Institute of Intelligent Transport Systems
    • /
    • v.11 no.6
    • /
    • pp.49-59
    • /
    • 2012
  • Recently, various alternatives for safety and efficiency of commercial vehicles have been considered, and one of the new alternatives is the application of a digital tachograph. In Korea, the installation of a digital tachograph to commercial vehicles was regulated from 2011 and Korea Transportation Safety Authority developed e-TAS to analyze the monitoring data from digital tachographs installed in the order of 100 commercial vehicles. This study performs the potential impact analysis of the DTG installation, which includes a trend of dangerous driving, a trend of traffic accidents and cost-effective analysis, a trend of fuel consumption and cost-effective analysis, a cost-effective analysis of social benefits using e-TAS data. Depending on the frequency of dangerous driving, the participants are divided into three groups; high-dangerous group, average-dangerous group and low-dangerous group. The high-dangerous driving group shows lower km/liter than the low-dangerous driving group by 15% for buses and taxis and by 30% for trucks. About $CO_2$ emission, the difference becomes bigger; 25%, 25% and 42% for buses, taxis and trucks, respectively. Although this study is a short-term period analysis, the methodology will be applicable for the long-term period analysis with larger data.

The Enactment of Record Management Act and the Reform of the National Assembly Record Management System(1999~2008) (기록물관리법의 제정과 국회기록관리체제의 개편(1999~2008))

  • Lee, Seung-Il
    • The Korean Journal of Archival Studies
    • /
    • no.18
    • /
    • pp.37-89
    • /
    • 2008
  • The record management system of the National Assembly was remarkably reformed as 'Record Management Act' was enacted in 1999. At first, the records of the National Assembly had been managed by the general services division, the proceeding division and the stenograph division. But as Record Management Act was enacted, the system was remarkably reformed. 'The National Assembly Archives' was set up for the first time since the National Assembly was established in 1948. In addition, the proceeding division and the stenograph division were set up as 'the National Assembly Record Management Rules' were laid down. In result, The National Assembly Archives took to comprehensively manage records that had been scattered over 'the National Assembly Secretariat', 'the National Assembly Library' and otherwise, and so it had been true to its name. The two changes, the enactment of Record Management Act and the reform of the National Assembly record management system, well show how national records are managed by constitutional institutions. 'Governmental Document Regulations' was enacted ahead of Record Management Act, but there was no obligation to apply it to the National Assembly. But Record Management Act, enacted in the form of 'a law' in 1999, began to be in force even in constitutional institutions and therefore the National Assembly felt the need to take follow-up measures so as to bring the act to effect smoothly. As a part of follow-up measures, the National Assembly set up The National Assembly Archives and reformed the National Assembly Record Management Rules. This study was performed to ascertain how Record Management Act affected the National Assembly, how the National Assembly coped with the act, and how the record management system of the National Assembly changed.

An Empirical Study of User Perceptions on EMR Standardization Leading Medical & IT Convergence (의료·IT융합을 이끄는 EMR 표준화에 대한 이용자 인식 연구)

  • Lee, Ji-Eun;Nah, Suk-Gyu
    • Journal of Digital Convergence
    • /
    • v.13 no.5
    • /
    • pp.111-118
    • /
    • 2015
  • Electronic Medical Record(EMR) is medical record that has been saved electronically onto a computer. The standardization activities for EMR is actively underway as it may not only improve the overall quality of the medical services but as the value of medical big data (medical & IT convergence area) is being considered very important. One of the most important issues is ensuring the necessary and effectiveness of EMR standardization to the stakeholder. Researchers did an empirical study to find out how the doctors perceived the EMR standardization from both technical and economical perspective. The results of the empirical analyses showed that system quality and an economical value had a positive effect on perceived usefulness and intention to adopt EMR standardization, yet interoperability have only affected the perceived usefulness. Additionally, the economical value seemed to be the most important variable in forming a consensus in the need of EMR standardization.

A Study on the System of Confidential Record Management of the USA (미국의 비밀기록관리제도에 관한 연구 -대통령의 행정명령(EO)을 중심으로-)

  • Kim, Geun Tae
    • The Korean Journal of Archival Studies
    • /
    • no.59
    • /
    • pp.159-206
    • /
    • 2019
  • This study aims to analyze the details of the executive order of the president of the United States, which have been developed in the country's administrative system to institutionalize the guarantee of the people's right to know the classified records, as well as to protecting national secrets. This study also aims to present any implications for the development of the classified record management system of Korea. To this end, the previously issued EO concerning the classified records management were reviewed in terms of its classification, safeguard, and declassification. The analysis results showed that the EO by the president established and prescribed the special access program for national secrets, the system to exempt and suspend the automatic declassification, and the sanctions for protecting national secrets. The EO also established and prescribed the appointment system for the person with the authority to classify record, automatic declassification program, and Mandatory declassification review system, as well as the procedures for historical researcher and certain former government personal to access the classified records with the purpose of guaranteeing people's right to know. As a result, this study identified implications for the development of Korea's classified record management system, as follows : First, it is necessary to restructure the current classified record management system, by changing the operations that is dependent on the director of the National Intelligence Service to the one that is dependent on the President. Second, it is necessary to legislate a separate special law for the classified record management system. Third, a standing supervisory body should be established for the integrated management and for the consistent and routine supervision of the classified record management. Fourth, it is necessary to establish procedures to further review the classification of classified record to correct the defects of the current classification system, which has been abused and mismanaged by the national agencies and organizations that produce classified record.

Development of a simplified malnutrition screening tool for hospitalized patients and evaluation of its inter-methods reliability (입원환자의 초기영양평가를 위한 단순영양검색도구 개발 및 도구 간 신뢰도 검증)

  • Yun, Oak Hee;Lee, Gyuhwi;Park, Yoon Jung
    • Journal of Nutrition and Health
    • /
    • v.47 no.2
    • /
    • pp.124-133
    • /
    • 2014
  • Purpose: The current study was designed for development of a simplified malnutrition screening tool (SMST) for hospitalized patients using readily available laboratory and patient information and for evaluation of its reliability compared to well-established tools, such as PGSGA and NRS-2002. Methods: Anthropometric and biochemical measurements, as well as a few subjective assessments, of 903 patients who were preclassified by their nutritional status according to PGSGA were analyzed. Among them, a combination of factors, including age, BMI, albumin, cholesterol, total protein, hematocrit, and changes in body weight and food intake, were statistically selected as variables for SMST. Results: According to SMST, 620 patients (68.7%) were classified as the normal group and 283 patients (31.3%) were classified as the malnutrition group. Significant differences in age, albumin, TLC, BMI, hemoglobin, hematocrit, total protein, cholesterol, and length of stay were observed between the two groups. For inter-methods reliability, the screening results by SMST were compared with those by PGSGA and NRS-2002. The comparison with PGSGA and NRS-2002 showed 'Substantial agreement' (sensitivity 94.4%, specificity 88.4%, ${\kappa}$ = 0.747) and 'Moderate agreement' (sensitivity 96.1%, specificity 79.5%, ${\kappa}$ = 0.505), respectively, indicating that SMST held high inter-methods reliability. Conclusion: In conclusion, SMST, based on readily available laboratory and patient information and simple subjective assessments on changes in food intake and body weight, may be a useful alternative tool with a simple but reliable risk index, especially in resource-limited domestic hospitals.

Analysis of Medical Records and Development of Chest Pain Care Record in the Emergency Department (의무 기록 분석을 통한 응급실 흉통 간호 기록지 개발)

  • Choi, Gui Yun;Moon, Young Sook;Hong, Eun Seog
    • Korean Journal of Adult Nursing
    • /
    • v.18 no.4
    • /
    • pp.533-542
    • /
    • 2006
  • Purpose: The purposes of this study were to investigate medical records and to develop care records for management of patients with chest pain in the emergency department. Method: Retrospective review of the 42 medical chart of patients presented to the emergency department with chest pain were used. The collected data were analyzed with a frequency of items in the medical records. Results: In a frequency analysis of recorded items for doctors' chest pain assessment during history taking, the history/risk factors was the highest rank. The following ranks were 'commenced with when/timing, extra symptoms, place, nature, stay/radiate, alleviate/aggravate, intensity' in sequence. In a frequency of recorded items in nurse's progress notes according to nursing actions, the 'checking/monitoring' was the highest rank. The following ranks were 'performing, administering/injecting, referring/arranging, testing, preparing/catheterizing, teaching/informing' in sequence. Chest pain care records for the emergency department was designed, based upon data analysis and literature review. Conclusion: The designed records can be a rapid and effective approach tool for assessment and recording of patients with chest pain. Further research is necessary for evaluating the designed chest pain care records.

  • PDF

A Study on Current Status and Improvement Tasks of Records Classification in Government-funded Research Institutes (정부출연연구기관의 기록분류 현황과 개선과제)

  • Lee, Mi-Young
    • The Korean Journal of Archival Studies
    • /
    • no.53
    • /
    • pp.229-259
    • /
    • 2017
  • The purpose of this study is to find out the level of the classification system of the government-funded research institutes and to search the future direction of the classification scheme of these research institutes. As a result of analyzing the classification system and regulations of the 23 government-funded research institutes, it is found that the regulations of the records management of most institutions are basically based on other regulations before Public Records Act. In addition, there are not many institutions in which the record production system that reflects the Public Records Act is introduced, and the production and classification of the records are performed separately, and the classification scheme in which the organization classification and the functional classification are mixed is often used only as a reference tool for setting retention period. To overcome this situation, it is necessary to improve the regulation, classification scheme and system. The revision of the law at the national level and establishment of records management regulations at the institutional level should be made. A special classification scheme for 'research' which is a core function of the research institute should be designed and this classification scheme must be applied from the registration stage of records. The fact that the record management obligation is ignored and the production records are not properly managed is to deny the value of the research field records by themselves. I hope that the records management of government-funded research institutes will be moved in place as soon as possible and practical issues will be communicated to academia and good ideas for better development will be returned to the field of practice.