• Title/Summary/Keyword: 진료 기록

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Predictability of the completeness of medical recording of quality of care for inpatients (의무기록 완성도의 입원환자 진료적정성에 대한 예측도 평가)

  • Park, Un Je;Park, Eal Whan
    • Quality Improvement in Health Care
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    • v.3 no.2
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    • pp.60-68
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    • 1997
  • Background : Medical records are used to assess clinical performance of physicians and quality of care. The contents which are written in medical records are considered as the objective evidences to know what the doctors think about the patient's problems. But the problem to use medical records as the assessment tools is the incompleteness of medical recording. The purpose of this study is to know if the completeness of medical recording is correlated to quality of care for inpattients and it can predict physicians's quality of care. Method : 32 clinical physicians reviewed 200 patients' medical records who were selected randomly from the inpatients who were admitted to the university hospital during July, 1995 and June, 1996. The reviewers used the structured evaluation questionnaires which were composed of two part. One part evaluated the completeness of the medical recording and the other evaluating appropriateness of diagnosis and treatment processes. We summated the scores of each items and calculated percentile scores. Results : The mean percentile score of completeness of the medical recording was 67.9% in 1995 and 79.8% in 1996. The mean percentile score of appropriateness was 52.2% in 1995 and 69.5% in 1996. This change between 1995 and 1996 was statistically significant. In non-surgical patients, the percentile scores of the completeness and those of the appropriateness were correlated positively and this correlation was statistically significant(p<0.05). In surgical patients, the positve correlation between the completeness and the appropriateness was also statistically significant(p<0.05). Discussion : In conclusion, the completeness of medical recording is considered as the good predictor of the quality of care for inpatients.

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Infection Control practices in accordance characteristic of Dental institutions -Daegu and North Gyeongsang Province around- (치과의료기관의 특성에 따른 감염관리실태 -대구, 경북지역을 중심으로-)

  • Sung, Mi-Ae;Yoon, Sung-Uk
    • Journal of Digital Convergence
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    • v.16 no.5
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    • pp.299-307
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    • 2018
  • This study survey research of infection control, wastewater management, and instrument disinfection according to characteristic at Daegu, Gyeongbuk Province In 2012 and 2017, the same 114 dental clinics to identify the infection management behavior and prevent infection of dental medical institutions. Scored mean 3.37 points on 8 items of infection control, 95.5% in "records of the patient's medical history", 1.8% in "presence of a wastewater facility." Scored 94.7% in "disinfection of metal trays", 17.5% in "storage from a spitting receptacle in the waste bin and commissioned management.", Scored higher in of infection control, wastewater management and instrument disinfection according to general characteristics and dental characteristics in 2017 than in 2012. Points were higher dental hygienist, University graduation, Type of duty was counseling and management, hospital or higher, Number of dentist(dental hygienist, chair, patient) was high. Therefore raise a need for infection control into consideration the dental characteristics and education and promotion regardless of the hospital size.

Developing Standard Transmission System for Radiology Reporting Including Key Images (Key Image를 포함한 방사선과 판독결과지 표준전송시스템 개발)

  • Kim, Seon-Chil
    • Journal of radiological science and technology
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    • v.30 no.1
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    • pp.47-51
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    • 2007
  • Development of hospital information system and Picture Archiving Communication System is not new in the medical field, and the development of internet and information technology are also universal. In the course of such development, however, it is hard to share medical information without a refined standard format. Especially in the department of radiology, the role of PACS has become very important in interchanging information with other disparate hospital information systems. A specific system needs to be developed that radiological reports are archived into a database efficiently. This includes sharing of medical images. A model is suggested in this study in which an internal system is developed where radiologists store necessary images and transmit them in the standard international clinical format, Clinical Document Architecture, and share the information with hospitals. CDA document generator was made to generate a new file format and separate the existing storage system from the new system. This was to ensure the access to required data in XML documents. The model presented in this study added a process where crucial images in reading are inserted in the CDA radiological report generator. Therefore, this study suggests a storage and transmission model for CDA documents, which is different from the existing DICOM SR. Radiological reports could be better shared, when the application function for inserting images and the analysis of standard clinical terms are completed.

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Efforts to Improve Antibiotic Prescribing Trends for Acute Upper Respiratory Infections in a South Korean University Hospital (급성 상기도 감염에서 항생제 처방개선에 관한 연구)

  • Kang, Hye-Kyung
    • Korean Journal of Clinical Pharmacy
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    • v.22 no.1
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    • pp.47-54
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    • 2012
  • 목적: 급성 상기도 감염에 사용되는 항생제 처방유형을 조사하여 항생제 사용을 개선하는데 있다. 방법: 2011년 1월부터 6월까지 경상대학교 병원을 포함한 10개 국립대학병원을 대상으로 급성 상기도 감염에 사용한 항생제 처방율을 조사하고, 경상대학교병원에서 급성 상기도 감염에 사용한 2011년 1월부터 6월까지의 외래환자를 대상으로 항생제 처방 내역을 전자의무기록을 통하여 후향적으로 분석한 후 처방의를 대상으로 항생제 사용 적정성 검토를 위한 그룹미팅 및 교육, 급성 상기도 감염에 항생제 처방 시 경고 안내문을 보여주는 등 중재활동 후 2011년 12월에 처방유형을 조사 하였다. 결과: 경상대학교병원에서 2011년 1월부터 6월까지 급성 상기도 감염에 항생제 사용은 1739명의 상기도 감염 외래환자 중에서 874명 (42.3%)으로 나타났다. 진료과별 급성 상기도 감염에 대한 항생제 처방은 소아과, 이비인후과, 내과, 응급의학과, 호흡기내과, 흉부외과 등에서 처방하였으며 소아과에서 1044명의 상기도 감염환자 중 556건(53.3%)로 가장 빈번하게 사용하였으며 처방율은 이비인후과에서 58.9% (225/382)로 가장 높았다. 사용한 항생제로는 amoxicillin-clavulanic acid가 371례 (36.3%)로 가장 빈번하게 처방된 약제이며, azithromycin이 85례 (9.7%) 처방되었다. 급성 상기도 감염 중 급성 편도염에 항생제 처방율이 가장 높았으며 (70.8%, 80/113), 급성 인두염에 가장 빈번하게 사용되었다 (61.1%, 319/522). 균동정을 위한 혈액배양 의뢰 건수는 1739 상기도 감염 환자 중 15명 (항생제 미사용 4명, 사용 11명)이 의뢰되었으며 모두 음성이었다. 중재활동 후 2011년 12월 상기도 감염에 항생제 처방건수는 소아과에서 1건, 이비인후과에서 2건으로 나타났다. 결론: 처방의를 대상으로 적절한 항생제를 사용을 권장하는 지속적인 교육 및 항생제 처방시 경고 안내문을 띄우는 등의 중재활동과 지속적인 모니터링 및 피드백은 급성 상기도 감염에 있어서 항생제 처방유형에 변화를 보였다.

Suggestions for writing the medical records based on the symptoms in Sanghanron("傷寒論") (상한론 증상에 근거한 진료기록부 작성에 대한 제언)

  • Kim, Sang-Un;Lee, Hong-Kyu;Jung, Hyun-Jong
    • The Journal of the Society of Korean Medicine Diagnostics
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    • v.18 no.2
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    • pp.85-110
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    • 2014
  • Objectives This study intends to present the writing of standardized medical records based on Korean medicine on the basis of the Sanghanron symptoms. Methods 1. Excluding the sentences unrelated to the Sanghanron symptoms, the symptoms in the rest of sentences were extracted. 2. Classifying the extracted symptoms as per the review of system, the similar symptoms were integrated. 3. Calculating the frequencies of each symptom, each strain rate was calculated. Results & Conclusion: 1. Resulting from the analysis on 378 sentences in Sanghanron, a total of 1566 different symptoms were extracted. 2. As results out of total, the symptom related to the temperature sensation accounted for 17.9%, that related to sweat did 6.5%, that related to pulse did 12.4%, that related to eye and nose and mouth and tongue and throat as well as thirst did 7.7%, that related to stool did 11.6%, that related to urination and urinary organs did 4.9%, that related to language and mind and sleep and agitation as well as heart did 10.0%, and that related to vomiting and abdomen as well as digestive organs did 15.4%. 3. There were found many symptoms were described in accordance with the severity of basic expressions. For examples, in case of fever, there were mild fever and high fever, and in case of sweat, there were profuse sweating and slightly sweating. 4. To create the medical records for cold damage disease, it may necessary to consider the factors to be recorded as per each symptom and write the detail of each symptom.

Relactation in the Lactation Clinic (수유 클리닉에서의 재수유)

  • Cho, Su Jin;Lee, Keun
    • Clinical and Experimental Pediatrics
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    • v.48 no.10
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    • pp.1050-1054
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    • 2005
  • Purpose : Relactation refers to the re-establishment of a milk supply and nursing after the cessation of nursing for a variable period. We aimed to analyze the practical issues related to successful relactation in the lactation clinic. Methods : The medical records of 51 mothers who had visited the lactation clinic for relactation were retrospectively analyzed. Breastfeeding greater than 90% was considered to as relactation success. Perinatal characteristics, the number of visits to the clinic, need for medication and the breastfeeding supplementer, and the reason for failure were analyzed. Results : Relactation appears to be easier for women who had lactated previously. With optimal care, support and motivation, some who had never lactated were able to start lactation. Conclusion : Relactation is a practical method to ensure breastfeeding in motivated women. Supplemental use of drugs and the breastfeeding supplementer system contribute to the success of relactation.

Suggestions for writing the medical records based on the symptoms in Geum-gwe-yo-ryak(『金匱要略』) (금궤요략 증상에 근거한 진료기록부 작성에 대한 제언)

  • Kim, Sang-Un;Jung, Hyun-Jong
    • The Journal of the Society of Korean Medicine Diagnostics
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    • v.19 no.1
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    • pp.11-34
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    • 2015
  • Objectives This study intends to present the writing of standardized medical records based on Korean medicine on the basis of Geum-gwe-yo-ryak symptoms. Methods 1. Excluding the sentences unrelated to the Geum-gwe-yo-ryak symptoms, the symptoms in the rest of sentences were extracted. 2. Classifying the extracted symptoms as per the review of system, the similar symptoms were integrated. 3. Calculating the frequencies of each symptom, each strain rate was calculated. 4. The above results were compared with the results of existing similar study on Sang-han-ron("傷寒論") symptoms Results Conclusion 1. Resulting from the analysis on all sentences in Geum-gwe-yo-ryak, a total of 1486 different symptoms were extracted. 2. As results out of total, the symptom related to the temperature sensation accounted for 12.4%, that related to sweat did 3.8%, that related to thirst did 3.8%, that related to edema did 3.4%, that related to musculoskeletal system did 6.9%, that related to breathing did 8.6%, that related to chest and hypochondrium did 6.2%, that related to abdomen did 9.5%, that related to digestive system did 9.6%, that related to stool did 6.4%, that related to urination and urinary system did 5.7%, that related to mouth, eye, ear, nose, throat did 5.3%, that related to skin did 4.5%, that related to language, mind, sleep and emotion did 6.7%. 3. Compared with Sang-han-ron, Edema appear only in Geum-gwe-yo-ryak. Therefore, edema may be a characteristic symptoms of miscellaneous disease.

Construction of Static 3D Ultrasonography Image by Radiation Beam Tracking Method from 1D Array Probe (1차원 배열 탐촉자의 방사빔추적기법을 이용한 정적 3차원 초음파진단영상 구성)

  • Kim, Yong Tae;Doh, Il;Ahn, Bongyoung;Kim, Kwang-Youn
    • Journal of the Korean Society for Nondestructive Testing
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    • v.35 no.2
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    • pp.128-133
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    • 2015
  • This paper describes the construction of a static 3D ultrasonography image by tracking the radiation beam position during the handy operation of a 1D array probe to enable point-of-care use. The theoretical model of the transformation from the translational and rotational information of the sensor mounted on the probe to the reference Cartesian coordinate system was given. The signal amplification and serial communication interface module was made using a commercially available sensor. A test phantom was also made using silicone putty in a donut shape. During the movement of the hand-held probe, B-mode movie and sensor signals were recorded. B-mode images were periodically selected from the movie, and the gray levels of the pixels for each image were converted to the gray levels of 3D voxels. 3D and 2D images of arbitrary cross-section of the B-mode type were also constructed from the voxel data, and agreed well with the shape of the test phantom.

Systemic Amyloidosis in a Cocker Spaniel (Cocker spaniel 견에서 발생한 전신성 아밀로이드증)

  • Pak Son-Il;Kim Doo;Han Jeong-Hee
    • Journal of Veterinary Clinics
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    • v.23 no.2
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    • pp.186-189
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    • 2006
  • A 7-month-old female Cocker spaniel dog was examined for chronic anemia. Based on information provided by local clinician the patient had had a 'flu-like' illness three weeks before submission of the sample, had a fever of $40.9^{\circ}C$, and had mild hepatomegaly. This dog had also history of weight loss, vomiting, anorexia, dehydration, lethargy, ascites, polyuria and polydipsia. A blood smear showed non-regenerative anemia. Thoracic radiograph showed irregular shadowing in the left mid-zone. Serum biochemical results showed a hypercalcemia, azotemia, hypercholesterolemia, hyperphosphatemia, hypoalbuminemia, and metabolic acidosis. Results of urinalysis showed proteinuria, slightly acidic with isosthenuria. Histopathologic examination of tissue sections revealed amyloid deposits in multiple sites including kidneys, liver and spleen.

A Study on Causality in Medical Civil Liability (의료민사책임에서의 인과관계에 관한 소고)

  • Baek, Kyoung-Hee
    • The Korean Society of Law and Medicine
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    • v.17 no.2
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    • pp.57-81
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    • 2016
  • It can determine the outcome of the lawsuit whether or not there is a causality between the medical malpractice of a physician and the patient's injury when the patient is filing a lawsuit against the physician in order to pursue civil liability for a medical accident. In medical malpractice lawsuits, it is not easy to judge causality between different civil cases because of the special nature of medical care. Also, information such as medical records is concentrated on doctors and the medical knowledge of the patient is relatively insufficient compared with the doctor. Therefore, it is recognized through medical malpractice lawsuits that the burden of proof of the causality burdened by the plaintiff patient is relaxed. In this paper, I examine the legal theory on how to recognize causality in medical civil liability and then concern the attitude of the case in Korea, which is divided into the types of the causality - such as the case of general medical practice, explanation duty, no causality with medical malpractice.

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