• 한국의료질향상학회지
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• 제4권2호
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• pp.174-183
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• 1997

Background : Medical records thought to be reflecting the quality of medicine. By this ground, examination of medical records can be served to evaluate, and to improve the quality of medical care. To examine the medical records, we need some standards or checklists which can be used to sort out the problems. Methods: We developed checklists for medical records evaluation. We studied 1,677 medical records about its completeness using this checklists in one educational hospital. Survey was completed by 5 well trained staffs of medical record department. Results are analyzed. SPSS/PC+ program was used for statistics. Results : 13.8% of discharge summary was incomplete. Recording of the demographic information was also poor in incomplete medical records compared to complete ones. Progress note was recorded average 4.16 times during 11.9 hospital days. After 4th hospital day, recording rate of progress note dropped sharply. Rate of professor's signature on operation records was poor(27%). He or she who described the discharge summary well also wrote progress note well. Conclusions: Fill-up of demographic date should be stressed during medical record education program. Strategy to create the environment emphasizing the responsibility of professor on quality medical record should be made. We suggest new index (number of records/hospital stay) for the evaluation of completeness of progress note.

• 한국화재소방학회논문지
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• 제24권1호
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• pp.64-71
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• 2010

이 연구를 위해 2009년 1월1일부터 2009년 2월 8일 까지 일개 종합병원에 119구급대로 내원한 모든 환자의 구급활동일지 255부를 조사하였다. 구급활동일지의 전체 기재율 62.1%, 가장 높은 항목은 환자 인수자에 대한 기록으로 100.0%, 가장 낮은 항목은 의사지도에 관한 항목으로 0.4%로 나타나 기대치에 미치지 못한 것으로 조사되었다. 효율적인 응급의료 정보전달매체로서의 119구급활동일지의 기재율을 높이기 위해서는 전문 인력의 확충과 의료진의 적극적인 관심 및 피드백, 구급활동일지의 항목 배열의 규칙성, 기록의 중요성에 대한 지속적인 교육이 필요할 것으로 사료된다.

• 한국병원경영학회지
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• 제13권1호
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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.

• 한국콘텐츠학회:학술대회논문집
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• 한국콘텐츠학회 2016년도 춘계 종합학술대회 논문집
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• pp.391-392
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• 2016

In Japan, the children with problem behavior have been called the difficult children. However, the definitions of the difficult children in the medical, health, childcare and education are different. As a result, it is difficult to support for the needs of children. In addition, the difficult children have been influenced by the subjectivity of the teachers. IN-Child (Inclusive Needs Child) is defined by the result of this study. IN-Child means "Child in need of inclusive education by a team, including experts. It does not depend on intellectual and developmental delays due to physical, mental, home environment." We developed the IN-Child record that enables the educational diagnosis of IN-Child. IN-Child record was made to organize and analyze of the items by experts including 3 researchers and 2 teachers. As a result, it was classified into two domains of "cause" and "effect". The domain of "cause" is classified by two domains of "physical" and "mental". The domain of effect is classified by two domains of "daily living" and "learning".

• 대한방사선기술학회지:방사선기술과학
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• 제44권5호
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• pp.513-523
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• 2021

The purpose of this study was to discuss the required items and feasibility of medical records of radiological examinations performed by radiological technologists at medical institutions. An online survey was conducted to a total of 10,000 radiation-related workers, of which 1,026 (10.3%) responded. As a research method, self-made questionnaires were used. The online survey was conducted from September 10 to September 20, 2021 for the survey period. For response data, a Chi-square test was performed according to demographic characteristics using SPSS 27.0 version (IBM Inc., Chicago, Ill, USA), and it was judged to be significant when the P value was less than 0.05. The reliability of the questionnaire response was found to be Chronbach α=0.933. More than 90% of the medical records related to radiological examinations are necessary, and they answered that a curriculum, remuneration curriculum, and legal system for medical records should be prepared. More than 90% of the respondents agreed with the proposal of the Radiological Technologist Independent Act for legal preparation, and most of the information required for medical records is currently recorded in DICOM images. According to the demographic characteristics, the medical record requirement for radiological examination, curriculum, continuing education, and legislation were found to be higher with higher education and higher with longer working experience. In addition, most of the radiology departments showed a high demand for medical records, so most of them responded positively to the medical records requirements for radiological examinations. This study analyzed the medical record requirements for radiological examinations, and as shown in the results, medical record requirements for radiological examinations was found that most radiological technologists felt need for the new law and supported it. In addition, if the information recorded in the DICOM image is used, it is considered that medical records could be easily prepared without additional work by the radiological technologists.

• 디지털융복합연구
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• 제13권7호
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• pp.229-238
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• 2015

본 연구에서는 직무의 표준화 방안으로 국가직무능력표준을 개발하여 이를 교육과정 전반의 기초자료로 활용하고자 하였다. 연구기간은 2014년 6월 21일부터 2014년 11월 30일 까지였다. 본 연구를 위해 연구진 외 산업현장전문가, 교육훈련전문가, 직무분석전문가로 구성된 전문가 풀을 구성하였다. 의무기록 분야에서 수행되어야 하는 직무명을 의료정보관리로 정의하고 산업현장의 요구와 특성이 향후 교육훈련에 조화롭게 적용될 수 있도록 직무에 필요한 능력단위 총 12개, 능력단위요소 총 43개, 경력수준 별 필요한 능력단위 등을 도출하여 의료정보관리 국가직무능력표준안을 개발하였다. 끝으로 개발된 표준안은 산업현장 검증을 거친 다음 국가직무능력표준으로 완성하였다.

• 디지털융복합연구
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• 제15권10호
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• pp.377-386
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• 2017

본 연구에서는 의무기록사의 의료정보관리 능력을 향상시킬 수 있는 교육용 의료정보관리 프로그램을 개발하였다. 교육용 의료정보관리 프로그램은 8개월 동안 vb.Net으로 개발하였다. 데이터베이스는 학습자가 데이터의 구조를 쉽게 이해하고 파악할 수 있는 ACCESS의 Database를 이용하였다. 학습자는 의무기록을 분석하여 퇴원분석 및 암등록 프로그램 그리고 미비기록 프로그램을 이용하여 데이터를 입력한다. 데이터를 입력하고 저장한 후에 의료정보관리 프로그램을 이용하여 데이터베이스의 구조를 이해하고 분석하여 의료정보를 생성할 수 있다. 교육용 프로그램은 데이터베이스에서 필요한 데이터를 SQL을 통하여 직접 추출하고, 다양한 의료정보를 생성해봄으로써 학습자의 의료정보관리 능력을 향상 시킬 수 있다. 하지만 교육용 프로그램이면서 학습자의 프로그램 운영에 대한 평가체계가 마련되지 않았다. 이에 따라서 다음 연구에서는 학습자 평가를 위한 의료정보관리 프로그램의 평가시스템을 개발해야 할 것이다.

• 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.

• 한국콘텐츠학회논문지
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• 제17권10호
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• pp.483-491
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• 2017

국내 의료기관별 전자의무기록 시스템의 높은 보급률에 비해 진료정보교류는 활성화되어 있지 않다. 본 연구는 진료정보교류가 도입되고 확산될 수 있도록 최근에 신설된 "의료법" 및 하위법령을 고찰하였다. "의료법" 및 하위법령에서는 환자의 동의하에 진료기록을 의료기관 간 전송할 수 있도록 하였으며 안전한 진료정보교류를 지원하기 위해 진료기록전송지원시스템을 구축 운영할 수 있도록 하였다. 이 외에도 표준적용 및 상호운용성 확보를 위한 전자의무기록 시스템의 인증제도 시행을 명시하고 있어 주목된다. 진료정보교류에 대한 법제도적 근거가 마련되었으나 진료정보교류의 성공적인 도입 및 확산을 위해서는 개발자 대상 교육, 인증체계 마련, 인센티브 제도 마련, 진료정보교류에 대한 홍보 활동 강화 등 지속적인 정책개발 및 연구가 필요할 것이다.

• 보건의료생명과학 논문지
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• 제9권1호
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• pp.1-9
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• 2021

본 연구에서는 한국보건의료정보원에서 실시하는 EMR 인증기준울 이해할 수 있도록 보건의료정보관리 실습 프로그램에 인증기준을 추가한 모델을 연구하여 제시하였다. 실습 프로그램은 EMR 인증제의 기능성 기준에 해당하는 환자정보관리를 실습하고 이해할 수 있도록 보건의료정보관리 교육시스템에 환자정보관리에 대한 인증기준 기능을 추가하였다. 환자정보관리를 위한 EMR 인증기준 실습프로그램은 다음과 같은 인증기준으로 구성되었다. 등록번호 및 인적사항 관리, 진료예약 일정관리, 인적사항 수정이력관리, 동명이인 구분자 표시, 다중 등록번호 통합관리, 식별정보를 이용한 환자 검색, 진료형태에 따른 환자 검색, 수술시술 동의서 기록·조회, 개인정보활용동의서 기록·조회, 연명의료결정정보 표시, 외부 의료기관문서 등록·조회, 외부 검사결과 등록·조회. 이와 같이 인증기준에 의한 보건의료정보시스템의 기능을 운영하여 실습해봄으로써 인증기준의 기능성 영역에서 환자정보관리의 인증기준과 내역을 이해하고 실습할 수 있다. EMR 인증 기준에 맞춰 환자정보관리 실습을 수행해봄으로써 전자의무기록시스템에서의 표준화된 환자정보관리를 이해할 수 있다. 또한 EMR 인증기준의 기능을 확인할 수 있기 때문에 의료기관에서 보건의료정보관리사의 전자의무기록시스템의 관리 능력을 향상시킬 수 있을 것이다.