• Journal of the Korean hospital association
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• v.18 no.4 s.163
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• pp.37-40
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• 1989

• Journal of Hospice and Palliative Care
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• v.7 no.1
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• pp.49-63
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• 2004

Purpose: The Hospice Oriented Medical Record (HOMR) was developed for assessing the pain and symptoms of terminal cancer patients. Methods and Results: The HOMR consists of an instruction for users and 2 assessment pages which include the graph showing vital signs (temperature, blood pressure, pulse, respiration rate and pain score), current problem lists, performance status, laboratory data, pain characteristics and management, sedation score, associated symptoms and drug side effects, etc. Pilot study was performed in the inpatient Hospice Care Unit in Guro Hospital, Korea University Medical Center. Because an one-week progress data was recorded in HOMR as a flow sheet, the patient's condition and pain control status could be seen at a glance. Conclusion: The HOMR is useful for assessing the terminal cancer patients because it is simple and convenient to use. Further research is needed before it can be universally used in the clinical settings.

• Quality Improvement in Health Care
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• v.15 no.1
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• pp.113-120
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• 2009

문제: 의무기록 질 관리의 어려움 목적: 의무기록의 질 향상 의료기관: 고려대학교 의료원 안암병원 의료정보팀 질 향상 활동: 의무기록의 질 향상을 위해 입퇴원기록지 24시간 이내 작성율 향상, 입원기록지 24시간 이내 작성율 향상, 외과계 N-C 기재율 감소, 경과기록지 작성율 향상, 일일입퇴원기록지 작성율 향상, STAFF 서명 완성일 단축 활동을 하였다. 개선효과: 의무기록 작성에서 같은 내용을 반복 작성해야 하는 번거로움을 해소하였고, 작성자(의료진) 중심의 프로그램 개선과 개발된 프로그램의 지속적인 모니터링으로 의무기록의 질이 향상되었다.

• 한국호스피스완화의료학회:학술대회논문집
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• 2004.07a
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• pp.99-99
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• 2004

• Journal of Digital Convergence
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• v.20 no.5
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• pp.681-693
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• 2022

The purpose of this study is to suggest a plan to utilize atypical data in the health care field by inferring standard medical terms related to the musculoskeletal system through keyword network analysis of medical records of patients hospitalized for musculoskeletal disorders. The analysis target was 145 summaries of discharge with musculoskeletal disorders from 2015 to 2019, and was analyzed using TEXTOM, a big data analysis solution developed by The IMC. The 177 musculoskeletal related terms derived through the primary and secondary refining processes were finally analyzed. As a result of the study, the frequent term was 'Metastasis', the clinical findings were 'Metastasis', the symptoms were 'Weakness', the diagnosis was 'Hepatitis', the treatment was 'Remove', and the body structure was 'Spine' in the analysis results for each medical terminology system. 'Oxycodone' was used the most. Based on these results, we would like to suggest implications for the analysis, utilization, and management of unstructured medical data.

• Quality Improvement in Health Care
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• v.14 no.1
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• pp.69-74
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• 2008

문제: 전자의무기록(EMR) 시행 후 의무기록 정리율의 저하와 질적인 측면에서의 충실성과 정확성에 대한 문제점이 제기되었다. 목적: 전자의무기록의 정리율과 충실성 검토를 통하여 문제점을 파악하고 개선점 찾아 의무기록 정리율을 향상시키고 충실성을 높이고자 하였다. 의료기관: 서울시에 소재한 대학병원 의무기록과 질 향상 활동: 전자의무기록의 문제점을 개선하기 위하여 사용자 편의를 위한 EMR 프로그램 수정 및 보완, 진단 수술 관련 작업, 업무개선, 교육, 홍보 등의 활동을 실시하였다. 개선효과: 의무기록 정리율, 전자인증미비, 경과기록 기재일수, 퇴원요약 주진단 적합률, 기록지별 필수항목 기재율, 충실성에서 향상이 이루어졌다.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.19 no.3
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• pp.317-324
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• 2018

This study was performed to investigate changes in prenatal and delivery characteristics of married immigrant women and to provide basic data for developing maternal health care programs. Data collection was carried out for 6 weeks from September 7, 2016 through medical records, and it was divided into 5-year intervals (5 years before and after 2011 were compared). The survey records consisted of demographic, prenatal, and obstetrics characteristics, and the data were analyzed by frequency, percentage, Independent Sample T-test, and Chi-square test using the SPSS 23.0 program. The results were as follows. The prenatal and delivery characteristics of married immigrant women showed significantly increased inadequate weight gain during pregnancy, pregnancy complications, premature birth, low birth weight infants, and low apgar score. Therefore, based on these changes in married immigrant women, prenatal and postnatal health care programs are needed to prevent maternal and childbirth complications.

• Journal of Hospice and Palliative Care
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• v.3 no.1
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• pp.60-73
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• 2000

Purpose : The purpose of this study was to describe a total pain model in patients with terminal cancer and to identify factors relating to total pain using the Twycross Pain Management Model, which included physical, psycho-social and spiritual pain. Method : The study was a retrospective descriptive study. The first stage included 87 patients who received hospice service at Y hospital in 1997. The second stage included five model patients who suffer severe pain as selected by the four hospice nurses. Data collection was from 1) chart analysis and 2) in-depth interviews with the hospice nurses about their selected patients. Data analysis was performed using SPSS-WIN and content analysis. Result : 1) The main problems of 3 patient with terminal cancer were pain(77%), constipation (25.3%), family coping(35.6%), psycho-spiritual distress(17.2%)and other symptoms. 2. The Twycross model was a useful model. However, new items were added; loneliness, depression, and no improvement in condition as depression factors. In anger, new items were anger due to family neglect, at God and in relationships. The case studies identified the followsing; 1) Patient suffer from physical pain as well as multiple other symptoms when cancer is advanced. 2) Body concept, role change, threat to self concept, fear of pain, fear of death, anxiety, family conflict, financial burden, spiritual distress, hope for a cure, are all affected. Conclusion : 1) It is believed that the Twycross model is useful but further tests and revisions are necessary for deciding priorities in the care plan. 2) Pain management must improve culturally appropriate and family support, psychological, spiritual care are imperative for patient with terminal cancer. 3) Further study is recommended to test correlations of depression, anxiety, spiritual distress and family coping using valid instruments. A qualitative study on the spiritual journey of the patient with terminal cancer is also recommended.

• Korean Journal of Adult Nursing
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• v.18 no.4
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• pp.533-542
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• 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.

• The Journal of Korean Institute of Communications and Information Sciences
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• v.33 no.5B
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• pp.379-385
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• 2008

For the sharing and exchange of information between medical clinics, the clinical document has to be built on a standardized protocol such as a HL7-CDA. But it is difficult to exchange information between medical clinics because clinical document such as electronic medical record that include text and image, have different structure of document and type of expression. In this paper, we propose the electronic medical record system based on HL7-CDA that can share and exchange clinical information between medical institute. For this purpose, we have to design the schema of the clinical document architecture after we select the essential items of medical record and define templates. The proposed system can minimize integrating process and save parsing time when clinical information exchange and refer, by converting electronic medical record to base64 encoding scheme and integrate it in a XML document.