• 가정∙방문간호학회지
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• 제3권
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• pp.5-38
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• 1996

The objective of this study is to develope the record forms for the home care nursing. Through the literature review and 4 times of workshop participated with the health practitioner and nursing professors from July 1993 to March 1995, the standands of home nursing care, initial assessment tools, progress notes by diseases and the referral sheet were developed. The Community health practitioner were trained for home nursing care and participated with 5 nursing professors in the workshop to validate the content of the record forms. It is suggested that the more refinement of these record forms fased a defined conceptual framework in the various home nursing area is needed in the future.

• 대한전자공학회:학술대회논문집
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• 대한전자공학회 2009년도 정보 및 제어 심포지움 논문집
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• pp.402-404
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• 2009

The development of health information technology enables people to access, view and acquire personal health record. But still, there have been a number of obstacles such as the absence of the standard to realize the ideal Personal Health Record(PHR) system. In this study, we proposed the service model that serves periodic Health Record Summary which is made by a medical specialist to people who are in the busy lives. Healthcare data from EMR in a hospital including people generate themselves at home is sent to a physician to make a medical opinion, and then it is changed into Health Level 7 Continuity of Care Document(CCD) format for interoperability. After a physician writes his opinion about patient's health condition, it will send to people by email. People who receive the health record summary data by email can save them into a USB device to view own PHR and medical comments of a physician through a computer. It will help people managing their own health condition with an opinion of a medical specialist.

• 한국의료질향상학회지
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• 제2권2호
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• pp.46-54
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• 1996

Background : The medical record is a compilation of pertinent facts of a patient's life and health history, including past and present illness and treatment. It is written by the health professionals contributing to that patient's care. And the medical record is the permanent, legal document which must contain sufficient information to identify the patient, justify the diagnosis and treatment, and record the results. As such, it must be accurate and complete. So we try to analyze the medical record especially a kind of incomplete record, loose laboratory reports. Methods: During the one-year period(from January to December 1988), a medical record practitioner examine and analyze the record of laboratory reports at K Hospital in Seoul. A total of 320 loose laboratory reports for 3,818 admitted laboratory reports. And a medical record practitioner and a physician review and analyze the influencing factors for the various reasons of clinical and laboratory aspects. Result: The loose percentage by department is the highest in obstetrics(40.4%) but the highest loose rate is in pediatrics(25.0%). The most of omission is occurred in operation room(80.3%) than OPD(19.7%). The change of diagnosis is according to duration of laboratory and more changable in cancer patient. Conclusion : Regular analysis of the documentation in the medical record so it fulfills its purposes of communicating patient care information. So it serves as evidence of the patient's course of illness and treatment for various legal, reimbursement, and peer evaluation review. And it is very important aspect of quality assurance in medical activities.

• 한국정보처리학회:학술대회논문집
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• 한국정보처리학회 2011년도 춘계학술발표대회
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• pp.1218-1221
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• 2011

The development of the internet and information management has enabled new applications which include: Electronic medical record (EMR), intelligent transportation, environmental monitoring, etc. In this paper, we design and implement the Continuity Care Record(CCR) Data Stream management server that compiled with DSMS and DBMS in EMR system for processing, monitoring the incoming CCR data stream and storing the processed result with high-efficiency. The proposed system enables users not only to query stored CCR information from DBMS, but also enables to execute continue query for the real-time CCR Data Stream. By using of CCR Viewer Application users can view or update their personal health records even compare self health care records with standard health care records in order to monitor the healthy status, and the on line updating information would be minimized and medical error.

• 가정∙방문간호학회지
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• 제10권2호
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• pp.103-112
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• 2003

Purpose: The purpose of this study was to develope nursing activities record to improve home care nursing for postpartum women following a Cesarean section and newborns. Method: This study for instrument development had three phases: first, selection of nursing activities according to intervention, second, validation of the preliminary home care nursing activities, and third. application of the home care nursing activities. The subjects for validaton were 137 home care nurses and clinical nurses in department of maternity. Result: By Fehring's method, 116 nursing activities according to 19 interventions were included in the preliminary nursing activities record. Among them, 51 critical nursing activities and 65 supporting nursing activities were chosen. During the final process of validation, 121 nursing activities were included. Conclusion: In order to have systemic standardization of this record forms, replication and application in the various home nursing area is need in the future.

• 한국지능시스템학회논문지
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• 제22권4호
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• pp.507-514
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• 2012

PHR(Personal Health Record)의 표현, 통합, 교류를 위해 CCD(Continuity of Care Document)와 CCR(Continuity of Care Record)과 같은 XML 기반의 표준들이 개발되었고, 이들 표준에 기반하여 PHR 교환을 위한 다양한 연구들이 수행되고 있다. 이들 연구에서는 각기 다른 방법으로 CCD/CCR 문서의 처리 도구를 개발하여 사용하고 있으나, 이들 표준이 구조적으로 복잡하여 도구의 개발 및 수정이 쉽지 않다. 또한 PHR 관련 의료정보시스템의 상호운용을 위해서는 CCD와 CCR 문서간의 상호 변환이 필요하다. 따라서 본 논문에서는 XML에 기반하여 작성된 CCD와 CCR과 같은 의료정보 표준 문서를 처리하고 관리하기 위한 프로그램 설계 방법을 제안하였다. 그리고 제안한 방법에 기반하여 CCD/CCR 처리 도구를 개발하고, 이 도구를 이용하여 CCD를 CCR로 변환하기 위한 변환기를 개발하였다. 개발한 도구의 효용성 확인을 위해 경북대학교병원에서 만성질환 입원자를 대상으로 수집한 개인건강정보를 이용하여 CCD 문서를 생성하고, CCD 문서를 CCR 문서로 변환하는 실험을 수행하였다.

• 한국의료질향상학회지
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• 제5권1호
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• pp.16-26
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• 1998

Background : As many previous studies proved, the quality of medical record is thought to reflect the quality of care. In this study, we analyzed the relationship between the quality of record and some factors influencing the quality of record, especially the commitment of the attending physician. Method : We developed checklist for evaluation of medical record with 36 criteria. 300 inpatient records of 10 attending physicians' patients were evaluated and the quality' of records were scored. The attending physician's commitment to medical records were scored by 34 residents. The relationship of the quality of records with physician's commitment to records, and some other factors were analyzed. Results : More than 75% of the immediate postoperative notes on the progress note were missed. More than 69% of the contents of explanation about the procedures on the consent form or on the other forms were also missed. The physician whose quality score of records was the highest(78.9) got the highest commitment score. The score of attending physician's commitment to the record, and his seniority were positively related with the quality score of his medical records when number of patients and department were adjusted. Conclusion : The quality of the 5 forms of the record reviewed were evaluated as moderate or excellent except 2 or 3 items. The quality of record was positively related with the attending physician's commitment to the record, and the seniority of the physician.

• 대한간호학회지
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• 제7권1호
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• pp.1-9
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• 1977

Primary function of health record is that as tool of communication between the health processionals with the mutual goal, the promotion of health care standard. Studies have been carried out world over oil tile subject, among those, Weed's Problem-Oriented Health Record is considered a paramount achievement. This study was designed to assess tile possibility of implementing tile problem-oriented health record system through ail experiment in order to provide data for nurse administrators infiltrating reformation of recording system and format. Record of 29 patients admitted at Korea University Hospital, Seoul, from March through June, 1976 for 4 to 14 days were sampled. Nursing notes were recorded by research assistants; senior nursing student trailed extensively by the researcher oil Problem-Oriented Records, oil Problem Oriented Nursing Record format (experimental group) and analysis were carried out comparative, with that of traditional nursing records noted by other nursing personnel (control group) on the same patient. Attitude towards Problem Oriented Nursing Record system and format were attained through questionaries responded by the 51 research assistants. Results are as fellows: Comparative analysis revealed that: 1. Assessment of patients' health problems recorded significantly more in traditional records. 2. Focus of health Problem differed; traditional records slowed significantly higher frequency in medical and procedure as focus while problem oriented records on nursing focus problems. 3. Problem- Oriented records were better organized, Mean value scores of attitude towards Problem- Oriented Records revealed that: Positive value scores on all 4 categories: 1) Assessment of nursing needs, 2) Nursing care planning 3) Patient progress assessment and 4) Tool of teaching and learning revealed that the Problem-Oriented Nursing Record is positively accepted by tile respondents. Recommendation Further experiments on implementation of Problem- Oriented Health Record are recommended: experiment involving all health professionals, in larger scope and longitudinal.

• 한국치위생학회지
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• 제16권4호
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• pp.567-575
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• 2016

Objectives: The purpose of the study was to investigate dental care effects of periodontal diseases patients with systemic diseases. Methods: The study subjects were ten patients. The study consisted of direct examination and interview survey. Direct examination comprised pocket depth, bleeding on the brush, O'Leary plaque record, salivary flow rate, and oral bacterial culture for three months. Results: The number of diabetic patients was eight. Four patients xerostomia and one of them had 0.7 mL per minute of salivary flow rate, decreased O'Leary plaque record, and bleeding in the brush. Those who received education were able to take control of plaque management. They recognized the need for oral care and had good self-management of oral care skills. Conclusions: The professional dental care and oral health education improved periodontal health and self-management skills of plaque in periodontal disease patients with systemic diseases.

• 동의생리병리학회지
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• 제30권6호
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• pp.458-465
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• 2016

The information relating to the health of person has been increasing. The information is such as medical information and personal health record and the information collected by utilization and dissemination of mobile devices. Therefore, the interest and demand for systems that can integrate and manage the Personal Health Record(PHR) is increasing. Quantity and quality of information that is collected from the patient can have a major impact on the diagnosis and treatment of Korean Medicine(KM) in clinical practice. Because closely observe the usual clinical symptoms of patients to utilize the treatment. But if the interview when memories are not sure of the correct answer does not get much easier to find exactly the symptoms. So when recording original symptom(素證) and daily subjective symptom can be helpful for care. Therefore, the personal health care services that can record and manage and own is necessary based on KM. In this paper, we propose Korean Medicine Personal Health Record Platform(KM PHR Platform). We have selected the significant symptoms that mean to the personal records from symptom information required for diagnosis in KM. And classifying and scoring as the symptoms were used as personal health care indicators. And significant symptoms were easily configure a screen that can be recorded. simple operation is recorded as a symptom. It was designed to reflect these functions. So KM PHR Platform helps to Personal health care. Doctor may be able to help in the diagnosis and prognosis observation by reference to shared symptom. We look forward to a variety of health services based on KM using a symptom, a medical record, personal health device information.