• Quality Improvement in Health Care
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• v.6 no.1_2
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• pp.80-91
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• 1999

Background : With the CQI concepts, which emphasize doing the right things right the first time, we tried to enhance the timely completion of medical records by changing the review process from retrospective method to concurrent one. Methods : Against the current retrospective QA activity, Medical record administrator did the concurrent QA of the inpatient medical records with the deficiency sheets. One general surgery ward was chosen as a trial one. The deficiency rate of the medical records of the discharged patients was compared before and after the enforcement of the system. Job analysis of the medical record departments was done about four tertiary care hospitals located in Seoul to estimate the cost and the time consumed by current system. Results : There was a little improvement in the completion rate of the medical records after the trial. The new system was effective. And job analysis showed that much money and time were wasted by current retrospective feedback system. Conclusion : Though the result was not so satisfactory, it should be considered that this test was a voluntary one and the interns and residents were not forced to complete the medical records during this trial period. If there be any strong motivation to complete the medical record in time, this system is sure to be succeed. As the DRG system requires the concurrent review of the medical records to confirm severity of the patient's illness and to assure the timely discharge, it is desirable to enforce this method with the DRG system together. DRG coding and reducing deficiency rate of the medical records can be accomplished simultaneously.

• Quality Improvement in Health Care
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• v.2 no.2
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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.

• Journal of the Semiconductor & Display Technology
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• v.13 no.2
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• pp.63-66
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• 2014

Managing electronic medical record is very difficult, because the currently electronic medical system is not designed standard that is uniform and proper. In this paper, in order to overcome this situation, we propose meta-data for the management of the electronic medical record as a single system. To this end, we first analyzed the research on electronic medical records and related standards. Second, we, on the basis of the analysis result, abstracted electronic medical record and entities related on electronic medical, and we designed an entity-relationship model. And finally, we have to complete the meta-data through the setting attributes in this entity-relationship model. Through this study, it was possible that we can complete metadata highly expressive medical records, and suggest an alternative for problem of current medical records systems.

• Journal of Digital Contents Society
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• v.11 no.2
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• pp.135-144
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• 2010

Medical records are very important records and should not be modified after creation. The current medical records are liable to improper modification. With the development of information technology, electronic medical records (EMR) are used widely. For the EMR, cryptographic primitives may be used to develop techniques to prevent medical record modofication. In this research, a technique to prevent improper medical record prevention is proposed. It uses crytographic primitives such as linked hash, digital signature, and electronic notarization. A prototype system is also developed for performance analysis. The proposed method makes the medical record modification impossible with a small amount of additional cost.

• Quality Improvement in Health Care
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• v.10 no.2
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• pp.144-153
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• 2003

1) Background: The hospitals of modem society, like any other business entities, have to constantly strive to secure their survival from aggressive changes and competition outside. In this unstable environment, effective leadership is one of the most effective strategies for securing organization's growth as well as stability. This study investigated types of leadership (transformational or transactional) that is dominant in medical record departments and compared it's effects on organizational commitment and job satisfaction of their organizational members by types. 2) Method: A questionnaire was developed and mailed to all medical record administrators working at general hospitals throughout the country except department directors (N=450). Of these, 150 useable questionnaires were returned and analyzed by t-test, multiple regression analysis using SPSS. 3) Results: The organizational commitment and job satisfaction were a little bit higher than moderate level, and that of leadership perceived by medical record administrators was also in moderate level throughout types. Significant characteristics (positively) related to organizational commitment and job satisfaction by univariate analysis were marital status (married), position (middle management) and both type of leadership. However transformational leadership was the only significant factor in leadership styles after considering all the factors related to organizational commitment and job satisfaction together by multivariate analysis. 4) Conclusion: The average organizational commitment and job satisfaction of medical record administrators was just in moderate level. Efforts should be made to increase them by improving leadership capacity of medical record directors, primarily by using transformational leadership approach.

• Journal of rehabilitation welfare engineering & assistive technology
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• v.3 no.1
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• pp.15-20
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• 2009

The purpose of this study was to investigate behavior to protect medical record among physical therapists(PTs). This study conducted a survey through the self-written questionnaires from 69 clinical PTs to understanding to protect patient' medical record. The result indicated that the behavior of PTs was not average 1, but the older PTs and healthier PTs, more protective patient's medical record(p<.01). The revision of PTs' behavior attitude and intention subjective was helpful to improve their behavior to protect patent's medical record.

• Korean Journal of Oriental Medicine
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• v.13 no.3
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• pp.45-51
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• 2007

This Study is to propose the method about statistical factor from the old oriental medical record in Korea. This Study reviews the statistical analysis recently published in the old oriental medical books which are in the Research Report by the Korea Institute of Oriental Medicine at 2007. The results reveal a disease factors, prescription factors.medicines factors, population factors and historical factors by the statistics. The results show that the old oriental medical record for a information system need the interpreting with a information analysts, a statistics analysts and an oriental medical doctors.

• Journal of Digital Convergence
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• v.11 no.6
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• pp.213-219
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• 2013

The purpose of this study is to suggest a plan for which Medical Record Technician, who has main task as efficient creation and management of medical information, is changed successfully to health information manager in IT-based medical environment. According to this research objective, it carried out an analysis on future model(To-be) for being changed into health information manger in addition to analysis of the current situation for task as medical record technician. The subject materials of analyzing the present status included 1) state-exam subjects for medical record technician 2) qualification examination subjects for health information manger 3) analytical data of the current task for domestically medical record technicians 4) symposiums and educational topics for the recent 3 years in Korean Medical Record Association. Future-model(To-be) data included 'HIM Professional Roles in E-HIM (R)' suggested by AHIMA(American Health Information Management Association). Through a comparative analysis of these materials, a role of being needed currently medical record technicians' new entry was analyzed to be Business change manager, IT training specialist, Consumer advocate, Clinical alerts and reminders manager, and Enterprise application specialist.

• Journal of Digital Convergence
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• v.11 no.8
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• pp.293-302
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• 2013

So far, DW(data warehouse) of hospital has been used as tool for analyzing patient-focused data. However, EMR(Electronic Medical Record) is established these days, so informal data which is record and video record could be useful to get some information for patient remedy, not as DW data. This study claims that need of establishing treatment-focused DW, not for hospital administration-focused DW which has been used lots of hospital DW. Also we discussed how CDW can be applied for real medication situation. At last, we deduct a relation past record of sick and wounded patient as Thesaurus searching method by real hospital data for establishing base of early-treatment system.

• Fire Science and Engineering
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• v.24 no.1
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• pp.64-71
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• 2010

Records of 255 patients was analyzed statistically according to the contents of the record form. T patients' records were collected through the visit of emergency department in one hospital by the 119 Emergency Medical Services system from January 1 to February 8, 2009. In conclusion, the total entry was the investigation of 119 ambulance run report in 62.1% of subjects. The highest record of receiving hospital item was 100.0% and the lowest record of medical control item was 0.4% of subjects. Increasing the entry of 119 ambulance run report in efficient emergency medical information delivery media needed to suggest that increasing the number of specialists on the staff, medical staffs have an active interest and feedback, rule to item arrangement of prehospital ambulance run report, continuous education in the importance of record.