• Title/Summary/Keyword: A Clinical History Recording

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A Clinical History Recording Management Scheme on the Multimedia Telemedicine

  • Kim Seok-Soo
    • Journal of information and communication convergence engineering
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    • v.2 no.3
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    • pp.157-160
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    • 2004
  • The paper's suggestion is about hereditary facts between family members. Diagnosing patients from the point of patients temporary conditions, and so performing primitive examinations and treatments, can lead not only to frequent wrong diagnoses, and to huge medical expenses and times to the patients, but even to critical situation of patients or taking lives away. As a means to cut these cases down to a minimum, sharing medical treatment information between family members is suggested. This approach makes possible understanding physical constitution and environment between family members, and can result in bringing a faster treatment effect if some family member suffers from a similar disease. This approach, since a participation in a family membership effectuates all of family members, can minimize the membership fees, thus enabling inter-family health care on a home doctor basis.

A Study on the Level of Medical Record Documentation and Agreement in the Information on the Patient's Past History (과거력 의무기록 정보의 기재정도 및 일치도 분석)

  • Seo, Jung-Sook;Yu, Seung-Hum;Oh, Hyohn-Joo;Kim, Yong-Oock
    • Korea Journal of Hospital Management
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    • v.13 no.1
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    • pp.42-64
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    • 2008
  • This study was conducted to evaluate the quality in medical records by analyzing its completeness through setting up the level of record on the patient's past history and through examining the actual medial records. Targeting the information on the patient's past history in interns' records, residents' records and nurses' records toward 403 inpatients who were admitted first in 2004 at an university hospital due to stomach cancer. We analyzed whether the charts were recorded or not, recording level, the satisfaction with the expectant level of the records in the hospital targeted for a research and the level of agreement. The results were as follows; first, as for the rate of recording those each items, they were high in the chief complaint & present illness and the past illness history. Depending on the group of recorders, the recording rate showed big difference by items. Second, as a result of measuring the level after dividing the recording level of items for the patient's past history from Level 1 to Level 4 by each item, the admission history, the past illness history, and the family history were about Level 3, and the smoking history, the medication history, the chief complaint & present illness, the drinking history and allergy were about Level 2. In the admission department, it was excellent in the interns' records for the medical department. Third, as a result of its satisfactory level by comparing the expect level of a record and the actual record by item in information on the patient's past history, which was expected by the medical-record committee members of the hospital targeted for a study. And forth, we analyzed the level of agreement with Kappa score in the level of 'Yes' or 'None' related to the corresponding matter in Level 1, in terms of information on the past history in the intern's record, the resident's record, and the nurse's record. The level of agreement in the resident's record & the nurse's record, and in the intern's record & the resident's record was from "excellent" to "a little good". There were differences in the level of completeness and in reliability for the information on the past history by the recorder group or by the admission department. The encounter process that was performed by the admission department or the recorder group, indicated the result that was directly reflected on the quality of medical records, thus it was required further study about the medical record documentation process and quality of care. The items that showed the high recording rate quantitatively were rather low, consequently we'd should develop the tool for the qualitative inspection and evaluate the medical records further. And the items were needed to be detailed in the record level were rather low, and hence there needed to be a documentation guideline and education by the clinical departments.

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A study of medical of Han Byung Lyun(韓秉璉) on Eui Bang Shin Gam (『醫方新鑑』) (『의방신감(醫方新鑑)』에 나타난 한병연(韓秉璉) 의학사상)

  • Kim, Dan Hee;Kim, Nam Il
    • The Journal of Korean Medical History
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    • v.22 no.1
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    • pp.31-45
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    • 2009
  • Eui Bang Shin Gam("醫方新鑑") is a classic on oriental medicines written by Shin Oh (新塢) Han Byung Lyun (韓秉璉) in 1913. It was written under the base of the writer's own experience as well as in the light of 36 other classics on oriental medicines such as Dong Eui Bo Gam ("東醫寶監"), Eui Hak Yip Mun ("醫學入門"), and Kyung Ak Jeon Seo ("景岳全書"). In an attempt to avoid difficult theories and list only the essential informations and formulas for clinical purposes, it attained its own characteristics of not only reorganizing Dong Eui Bo Gam in a pragmatic way but also explaining diseases classified in western medicines in oriental medicines' point of view as well as suggesting medicine formulas regarding such explanations. As a result, it is a complete and efficient medical classic through which one can gain knowledge in both classic oriental medicines and combination of western and oriental medicines. Its special features are making a separate chapter for cholera and Lao Zhai (勞瘵), which is also a contagious disease, and trying in the chapter to explain the diseases in words of oriental medicines; listing details of nine major epidemic and matching them with the diseases known in oriental medicines; and recording a case of enforcing sterilization and preventive injection against contagious diseases. The basic medical theory in Eui Bang Shin Gam are the yin-yang theory, the thesis of fire and water, the thesis of the exterior and the interior, Yun Qi Lun (運氣論), and four institutions of human body. In explaining the basic theories, the writer emphasized strengthening the yang of the body, under the influence of the thoughts of Zhang Ga Bin (張介賓). Since he put the importance of diagnosis first, the first chapter is about diagnosis. There are five different ways of diagnosing a patient mentioned in the book, and acupuncture, pulse, and medicines was considered crucial.

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Analysis of Existing Guidelines and Randomized, Controlled, Clinical Trials for Development of [Guideline of Clinical Trial with Herbal Medicinal Product for gastric cancer] (위암 한약제제 임상시험 가이드라인 개발을 위한 한약제제 무작위배정 대조군 임상시험 고찰)

  • Han, Gajin;Seong, Sin;Kim, Sungsu;Kim, Jinsung;Park, Jae-Woo
    • The Journal of Korean Medicine
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    • v.38 no.3
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    • pp.124-142
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    • 2017
  • Objectives: This study aimed to learn what should be considered in [Guideline of Clinical Trial with Herbal Medicinal Product for Gastric Cancer)] by analyzing the existing guidelines and clinical trials. Methods: The development committee searched guidelines for herbal medicinal product or gastric cancer developed already. Then, clinical trials for gastric cancer using herbal medicine were searched. The searched trials were analyzed in terms of inclusion and exclusion of participants, intervention, comparator, outcomes and trial design. Then, we compared the results of analysis with the regulations and guidelines of Ministry of Food and Drug Safety to suggest the issue that we will have to consider when making the [Guideline of Clinical Trial with Herbal Medicinal Product for Gastric Cancer]. Results: As a result, few guidelines for anti-tumor agent and clinical trial with herbal medicinal product were searched in the national institution homepage. In addition, 10 articles were searched by using the combination following search term; 'stomach neoplasm', 'herbal medicine', 'Medicine, Korean traditional', 'Medicine, Chinese Traditional', 'TCM', 'TKM', 'trial'. Most trials included gastric cancer participants with medical history of operation. The type of intervention was various such as decoction, granules, and fluid of intravenous injection. Comparators were diverse such as placebo, conventional treatment including chemotherapy and nutritional supplement. The most frequently used outcome for efficacy was quality of life. Besides, the symptom score, tumor response, and survival rate were used. Safety was investigated by recording adverse events. Conclusion: We found out some issue by reviewing the existing guidelines and comparing it with clinical trials for gastric cancer and herbal medicinal products. These results will be utilized for developing [Guideline of Clinical Trial with Herbal Medicinal Product for Gastric Cancer].

Common ECG pattern and underwriting risk assessment (언더라이팅시 흔하게 접하는 심전도 소견과 위험 평가)

  • Choi, So-Young
    • The Journal of the Korean life insurance medical association
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    • v.26
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    • pp.21-30
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    • 2007
  • ECG is included in certain medical examinations of insurance application, ECG has low specificity and sensitivity. So ECG is not usually used to diagnose specific diseases. But, ECG is not invasive and costs low. So ECG is usually used in underwriting. Actually in underwriting we meet various ECG patterns and diagnosises. Understanding of various ECG patterns is different between insurance medicine and clinical medicine. So We have to learn various ECG patterns and effects on mortality and morbidity. First considerations of ECG readings are age, sex, blood pressure, family history, smoking historyalcohol history and hyperlipidemia. These are predictors for possibility of disease. Also it is important to review recording ECG with proper skill. In this review I consider several ECG diagnosises that we meet frequently, which is, LVH, RVH, ST abnormalities, LBBS, RBBB, A-B blocks, several kinds of arrhythmia. We have to consider long term mortalities and morbidities of specific ECG patterns although applicants have no symptom and sign. And then we have to make underwriting manual according to specific ECG diagnosises and patterns and underwrite precisely ECG patterns according to insurance products. Nowadays coronary heart disease and other heart diseases are increasing in Korea. So we have to learn various ECG patterns and research mortalities and morbidities of abnormal ECG patterns. Also we have to apply to more broad, precise underwriting skills about ECG patterns and diagnosises.

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Comparative evaluation of the effectiveness of two innovative methods in the management of anxiety in a dental office: a randomized controlled trial

  • Panchal, Jay;Panda, Anup;Trivedi, Krishna;Chari, Deepika;Shah, Rushita;Parmar, Binny
    • Journal of Dental Anesthesia and Pain Medicine
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    • v.22 no.4
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    • pp.295-304
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    • 2022
  • Background: The first dental experience is vital in molding a child's attitude towards dentistry and dental outcomes. The cooperation of a child during dental treatment is essential to render successful and high-quality treatment. Dental anxiety is common in children undergoing dental treatment. The success of pediatric dental treatments and patient comfort depends on controlling the levels of patient anxiety in clinical settings. This study aimed to compare the effectiveness of the recorded maternal voice and virtual cognitive tool (Roogies application) in the management of pediatric dental patients. Methods: The study was carried out with children aged of 4-7 years [n = 80, (40 male and 40 female)], without any past dental history, and were randomly allocated into two groups. After informed consent was obtained, the entire procedure was explained to the parents. Anxiety was assessed pre-, during, and post-treatment by measuring pulse rate, and recording Venham Picture Test (VPT) scores. Group A [n = 40; 20 boys and 20 girls)] was provided with a headphone that played a recorded maternal voice. Group B [n = 40; 20 boys and 20 girls)] was administered the virtual cognitive tool. After conditioning the children, oral prophylaxis was performed for both groups. A comparative evaluation was conducted for each treatment session. Results: The intra-group comparison of VPT scores and heart rate for patients assigned to the recorded maternal voice showed a statistically significant difference in dental anxiety (P-value ≤0.001). Conclusion: This study demonstrated that a reduction in dental anxiety with the help of recorded maternal voice forms an important component of non-pharmacological behavior management. Alternatively, the use of a virtual cognitive tool as an anxiety-reducing technique can also be advocated.

Sick Sinus Syndrome (SSS) in a Maltese Dog Concurrent with Mitral Valve Endocardiosis (MVE) (말티즈견에서 발생한 Mitral Valve Endocardiosis (MVE)를 동반한 Sick Sinus Syndrome (SSS)에 대한 증례)

  • Park Chul;Jung Dong-in;Kim Ha-Jung;Kang Byeong-Teck;Kim Ju-Won;Lim Chae-Young;Yoo Jong-Hyun;Park Hee-Myung
    • Journal of Veterinary Clinics
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    • v.22 no.4
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    • pp.396-400
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    • 2005
  • A 13-year old, female Maltese dog was presented due to a five-month history of episodic syncope. A diagnosis of sick sinus syndrome (SSS) with mitral valve endocardiosis (MVE) was made based on history takings, physical and cardiac examination, complete blood count (CBC), serum chemistry profiles, radiography, electrocardiography (ECG), atropine response test, hormonal assay, and echocardiography. In this case, SSS was definitely diagnosed by evaluation of ECG recording following atropine administration. Clinical signs were improved with medical management of theophylline (THEOLAN, KunWha Pharm, Seoul, Korea, 20 mg/kg, PO, BID). After 10 more month survival, the dog, died of respiratory distress and shock during the operation of abdominal mass removal in local animal hospital. Unfortunately, we were not able to perform necropsy after death due to owner's decline. This case demonstrates that theophylline can be used in management oF dog with SSS.