• Title/Summary/Keyword: 의무기록지

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Postural Aberrations in Female Patients With Chronic Low Back Pain (만성요통 여성 환자들에서 발생되는 자세의 변화)

  • Oh, Duck-Won
    • Physical Therapy Korea
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    • v.7 no.4
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    • pp.1-7
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    • 2000
  • 이 연구의 목적은 만성요통 여성 환자들에서 나타나는 자세 이상을 평가하고 방사선적 변수들과 임상적인 변수들과의 상관성을 알아보는 것이다. 이 연구의 대상자는 만성요통 여성 환자 38명과 대조군 32명이었다. 변수의 측정은 모든 대상자들이 이완된 자세로 기립한 상태에서 방사선 검사를 실시한 후 경추전만각, 흉추후만각, 요추전만각, 그리고 요추경사각을 측정하였다. 대상자들의 연령과 통증기간은 의무기록지를 참고하였다. 자료분석은 요통군과 대조군의 방사선적 변수들 간의 유의한 차이가 있는지를 알아보기 위해 독립된 t-검정을 시행하였고, 방사선적 변수들과 임상적 변수들과의 상관성을 알아보기 위해 피어슨 상관분석을 시행하였다. 연구결과 만성요통 환자군과 대조군사이의 경추전만각(p<.05), 요추전만각(p<.001), 그리고 천추경사각(p<.01)에서 통계학적으로 유의한 차이가 보였다. 통증기간은 요추전만각과 통계적학으로 유의한 상관관계가 있었으며(p<.05), 경추전만각은 흉추후만각과 통계학적으로 유의한 상관관계가 있었다(p<.05). 또한 흉추후만각, 요추전만각, 그리고 천추경사각은 각각 상호간에 상관관계가 있었다(p<.05). 만성요통은 요추만곡의 변화를 초래하여 흉추부 및 경추부의 자세이상을 유발할 수 있다. 그러므로 요통으로 인하여 올 수 있는 신체 전반적인 자세이상을 미리 예측하고 이를 교정하여야만 장기적으로 올 수 있는 합병증들을 예방할 수 있을 것이다.

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Nursing Activities and Outcomes Related to Indwelling Urinary Catheterization from a Review of Medical Records and Interviews (의무기록지 분석과 간호사 면담을 통한유치도뇨관 관리에 관한 간호활동 및 환자결과)

  • Jang, Keum-Seong;Chung, Kyung-Hee;Choi, Ja-Yun;Yang, Jin-Ju;Park, Soon-Joo;Ryu, Se-An;Kim, Nam-Young;Sim, Jae-Youn
    • Journal of Korean Academy of Fundamentals of Nursing
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    • v.15 no.4
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    • pp.438-448
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    • 2008
  • Purpose: The purpose of this study was to identify nursing activities and to analyze patient outcomes related to indwelling urinary catheterization. Method: A review was done of 628 medical records from five units for patients admitted between January 1 and June 30, 2006. Twelve nurses who worked in the same units were interviewed. Results: In the interviews, nurses reported considering several non-invasive interventions prior to catheterization but there were no medical records of this activity. Results from the in-depth interviews showed that infection control activities such as urinary bag management were conducted but again there were no medical records. Seventy-five percent of the catheters were removed without prescription. In the medical records there were no notes for approximately 15%, on the time of first voiding and 80%, on volume of first voiding after removal of catheter. There was a significant difference in hospitalization days between the group catheterized for 5 days or less and the group catheterized for 6 days or more. Conclusion: Results indicate a need to close the gap between recorded and described activities and between current and best evidence based practice. Further study is needed to develop a standard recording system and guidelines related indwelling catheterization to decrease the gaps identified in this research.

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Neutropenia & Nutritional status during Chemotherapeutic cycle in Acute Myeloid Leukemia (급성골수성백혈병환자의 항암화학요법 주기내의 호중구감소증과 영양상태)

  • Kim, Myung-Hee;Kang, In-Soon;Jo, Ho-Yoon
    • Journal of the Korea Academia-Industrial cooperation Society
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    • v.10 no.2
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    • pp.438-446
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    • 2009
  • This study aims to investigate chemotherapy-induced neutropenia, nutritional status and both relation of patients with acute myeloid leukemia during 1st consolidation chemotherapy and the therapy-related cytopenic phase in order to determine more effective nutritional support. We review medical records of total 54 cases received first consolidation chemotherapy on P hospital in Busan. The duration of neutropenia(Absolute Neutrophil Count<$1000/{\mu}{\ell}$) is mean 14.78 days, neutropenia occur on mean 10th(9.54) day of chemotherapy(D10). The nutritional parameters of total protein, body weight, BMI showed no significant interval change during chemotherapeutic cycle except albumin, cholesterol. The neutropenia wasn't dependent on general factor of gender, age, comorbidities, Body Surface Area(BSA). The correlation wasn't revealed between neutropenia and nutritional status. In conclusion, although nutritional status didn't affect neutropenia, this study provides detailed information on the neutropenic response of acute myeloid leukemia patients during induction chemotherapy.

Pharmacokinetics of High-dose Methotrexate in Pediatric Patients with Osteosarcoma (소마 골육증 환자에서 고동량 Methotrexate의 Pharmacokinetics)

  • Nam, Taeg-Jong;Park, Gwang-Jun;Shin, Wan-Gyoon
    • Korean Journal of Clinical Pharmacy
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    • v.16 no.1
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    • pp.1-8
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    • 2006
  • Methotrexate(MTX)는 소아 골육종 환자에서 $12g/m^2$의 고용량을 사용하고 있다. 현재, 소아 골육종 환자에서 신기 능에 따른 고용량 MTX의 임상 약동학은 연구되어 있지 않다. 따라서 본 연구에서는 신기능에 따른 MTX 약동학을 이용하여 구내염을 최소화하는 방법을 제시하고자 하였다. 방법: 환자들의 의무기록지를 후향적 방법으로 검토하였다. 한 병원에서 골육종으로 진단받고, 치료 받은 환자들을 대상으로 정상 신기능군과 비정상 신기능군으로 나누었다. 두 군에 MTX 투여 후 혈중 농도를 각각 비교하였고, 최고 혈중농도도 비교하였다. 혈중 농도와 구내염의 관련성, CL, AUC와 구내염의 상관관계를 분석하였다. 각 군의 terminal half-life, CL, Vss의 평균과 mea residence time(MRT)의 평균을 구하였고, 두 군간 각각을 비교하였다 $({\alpha}=0.05)$. 결과: 환자는 6명이었고, 평가 가능한 총 MTX 투여 회수는 34회였다. MTX 투여 후 최고혈중 농도, 24,48 시간의 혈중농도는 통계적으로 유의성 있는 차이가 있었고, 72,96 시간에서의 농도는 두 군간 유의성이 없었다. 각 군에서 혈중농도와 구내염의 상관관계, 그리고 CL, AUC와 구내염의 상관관계는 발견되지 않았다. Vss를 제외한 모든 파라미터들(terminal half-life, CL, MRT)은 통계적으로 유의성 있는 차이가 있었다. 결론: 비정상 신기능 군에서 MTX 투여 시작 후 24, 48 시간에서의 혈중농도가 더 높고, 변동이 심했다. 또한 MTX의 CL는 감소했고, 혈중농도는 증가하였다. 이러한 사실로 MTX 투여 전 후 혈중 크레아티닌이나 또는 크레아티닌 청소율 모니터링이 필요하다는 것을 알 수 있으며, MTX 투여가 끝난 직후 그리고 그 이후 24 시간 간격으로 혈중 농도를 측정해야함을 알 수 있다.

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Exploratory Study on determinants of the Performance of Bayley Scales of Infant Development in Infants with High Risk (고위험집단의 Bayley영아발달 검사 수행에 영향을 미치는 요인 탐색)

  • Min, Dong Ok
    • Korean Journal of Childcare and Education
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    • v.1 no.1
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    • pp.83-101
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    • 2005
  • The present study applied Bayley Scales of Infant Development to Infants with High Risk to investigate the effects of determinants such as variables related to demographic variable, prenatal and perinatal and postpartal environments, and developmental indices in infancy. First, mental and motor development index were high in infants whose mothers had high in education, mothers had not had a disease during the pregnancy, mothers had not taken medicine during the pregnancy. Second, mental and motor development index were high in infants who had used an oxygen inhaler, incubator, and in infants who had been given a timely birth. Third, mental and motor development index were higher in infants whose mumbling and the initial speaking was normal than in infants whose development was late.

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A Study of Comparing the Paper-Based Medical Record with the Electronic Medical Record on the Level of Medical Record Completeness and the Accordance (종이의무기록과 전자의무기록의 기재 충실도 및 일치도 비교 연구 : 의사의 입원.퇴원기록지와 간호사의 입원.퇴원간호정보기록지를 중심으로)

  • Shin, A-Mi;Jung, Sun-Ju;Lee, In-Hee;Son, Chang-Sic;Park, Hee-Joon;Kim, Yoon-Nyun;Youn, Kyung-Il
    • Korea Journal of Hospital Management
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    • v.15 no.1
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    • pp.1-12
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    • 2010
  • This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor's admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor's admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor's admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking (p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.

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Database for Hospice Nursing in Electronic Medical Record (호스피스 전자기록을 위한 데이터베이스 개발)

  • Kim, Young-Soon;Lee, Chang-Geol;Lee, Kyoung-Ok;Kim, Ok-Kyum;Kim, In-Hye;Kim, Mi-Jeong;Hwang, Ae-Ran;Lee, Won-Hee
    • Journal of Hospice and Palliative Care
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    • v.7 no.2
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    • pp.200-213
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    • 2004
  • Purpose: The purpose of this study was to create an electronic nursing record form to build a hospice nursing process database to be used in the u-hospital EMR system. Specific aims of the study were: 1. To generate a complete, accurate, and simple electronic nursing record form. 2. To verify its appropriateness following documentation with the standardized hospice protocol. 3. To verify its validity and finalize the hospice nursing process database through discussion among hospice professionals. Methods: Nursing records from three independent hospice organizations were collected and analyzed by five expert hospice nurses with more than 10 years of experience, and a nursing record database was developed. This database was applied to 81 hospice patients at three hospice organizations to verify its completeness. Results: 1. An electronic nursing record form with completeness, accuracy, and simplicity was developed. 2. The completeness of the standardized home hospice service protocol was 95.86 percent. 3. The hospice nursing process database contains 18 items on health problems, 79 items on related causes and major symptoms, and 229 items on nursing interventions. Conclusion: The new nursing record form and database will reduce documentation time and articulate and streamline the working process among team members. They can also improve the quality of hospice services, and ultimately enable us to estimate hospice service costs.

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Home-Based Hospice Care Provided by a Free-Standing Hospice Center: Patients' Characteristics and Service Conditions (일개 독립형 호스피스 기관의 가정호스피스 이용자 특성 및 서비스 제공 실태)

  • Kim, Hyoung Suk;June, Kyung Ja;Son, Young Sun
    • Journal of Hospice and Palliative Care
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    • v.19 no.2
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    • pp.145-153
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    • 2016
  • Purpose: This study was conducted to investigate patients' characteristics and actual conditions of home-based services offered by a free-standing hospice center. Methods: A retrospective review was performed with the medical records of 75 patients who received home-based hospice care from a free-standing hospice center from January 2014 through December 2014. Results: Most patients (54.7%) were enrolled via self-directed referral. The reason for the service termination was death at home 25.3%, admission to a hospice ward 50.7%, hospitalization 22.6% and patients' refusal 2.7%. Seventy three patients had cancer, and two patients had ALS. Among all, 58.7% were in a dying phase, and 34.7% were almost completely bedfast at the time of their enrollment in this study. When they enrolled, the patients' physical symptoms were characterized as pain (89.4%), sleep disturbance (71.2%), urinary difficulties (35.8%) and defecation difficulties (47.8%). Among all, 77.4% terminated the home visit service within one month. The mean frequency of the home visits was 3.25 (${\pm}3.98$), and less than five in 82.7% of patients. The mean frequency of the phone service was 3.40 (${\pm}3.12$). The frequency of doctor's home visits was $1.21{\pm}0.79$ on average, and the figure increased when patients' conditions turned unstable. Conclusion: It is necessary to develop a home-based hospice care model with consideration of patients' characteristics and the actual service conditions delivered by free-standing hospice facilities.

Design and Implementation of a Nursing Records for the Nursing Process for Use Within the Health Level 7 Clinical Document Architecture (HL7 임상문서구조의 기반 한 간호과정을 위한 간호기록지의 설계 및 구현)

  • Kim, Hwa-Sun;Tran, Tung;Kim, Hyung-Hoi;Lee, Eun-Joo;Cho, Hune
    • Journal of Korea Multimedia Society
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    • v.9 no.8
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    • pp.1054-1066
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    • 2006
  • This study proposes a new paradigm hospital information system through the nursing classification system and design of the HL7 clinical document architecture (Health Level Seven CDA) for information-sharing among various healthcare institutions. Nursing information CDA are included coding systems of nursing diagnosis, nursing intervention, nursing activity and outcomes. And, we have developed CDA generator for active generation of XML document. This study aims to facilitate the optimum care by providing health information required for individuals to nursing specialists in real-time, to help improvements in health, to improve the quality of productive life. This study has the following significance. First, an expansion and redefining process conducted, founded on the HL7 clinical document architecture and reference information model, to apply international standards to Korean contexts. Second, we propose a next-generation web based hospital information system that is based on the clinical document architecture. In conclusion, the study of the clinical document architecture will include an electronic health record (EHR) and a clinical data repository (CDR), and also make possible healthcare information-sharing among various healthcare institutions.

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Evaluation of Critical Patient Severity Classification System(CPSCS) for neurocritical patients in intensive unit (신경계중환자에게 적용한 중환자 중증도 분류도구 연구)

  • Kim, Hee-Jeonh
    • Journal of the Korea Academia-Industrial cooperation Society
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    • v.13 no.11
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    • pp.5238-5246
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    • 2012
  • This study was done to identify the evaluation of CPSCS for neurocritical patients and provide effective nursing interventions for these patients. Data were collected from medical records of 203 neurocritical patients over 18 years of age who were admitted to the ICU of C University Hospital during the period from January 2008 to May 2009 and from October 2011 to December 2011. Collected data were analyzed through t-test, ANOVA test, Person's correlation analysis, trend analysis, stepwise multiple regression. The average CPSCS score was $112.09{\pm}18.91$ and there was a significant trendency for higher severity to lead to higher CPSCS's scores(survival: J-T:9.795, die: J-T:5.415, p=<.001). The scores of the respective areas follows measurement of vital sign($3.74{\pm}2.15$), monitoring($28.97{\pm}4.31$), activity daily living ($34.99{\pm}3.66$), feeding($.19{\pm}.98$), intravenous infusion ($18.20{\pm}8.27$), treatment/procedure ($16.93{\pm}4.90$), respiratory therapy($8.61{\pm}7.07$). By means of stepwise multiple regression analysis, the intravenous therapy & medication, respiratory therapy, activities of daily living, and monitoring area that contains the model showed a significant (F=2073.963, p<.001), and they explained 98.1% of CPSCS. These findings provide information that is relevant in designing interventions to enhance CPSCS among neurocritical patients in hospital.