• Quality Improvement in Health Care
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• v.4 no.2
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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.

• Journal of Integrative Natural Science
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• v.17 no.3
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• pp.105-112
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• 2024

In the present age of artificial intelligence and metaverse, research on the importance of data and the amount of data is actively being conducted. Among these data, medical data contains the most sensitive information of individuals, so research on data generation, storage, management, and disposal is urgently needed. This study analyzed the status of medical data management in the United States, Europe, and Korea, and identified and analyzed medical data management laws and implementation status through working-level staff working in medical sites. As a result of the analysis, about 70% of medical professionals were able to identify the absence of recognition and management of medical data. The survey subjects were limited to Gwangju and Jeollanam-do, and 237 medical workers were conducted. More than 54% of the awareness of medical record generation, storage, and management came out, but about 70% of the occupations except doctors, oriental doctors, and dentists did not recognize the medical record management method. As necessary for medical record management, cost and the need for professional managers were 91.4%. Through this study, it was confirmed that the expansion of legal education for medical workers, the enactment of related laws, and the need for sincere fostering of medical record managers were required.

• 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.

• 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.

• Journal of the Health Care and Life Science
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• v.11 no.2
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• pp.173-180
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• 2023

In this study, senior general hospital, general hospital medical institutions certified by the Electronic Medical Record System Management Portal in 2021 were surveyed on the recognition of changes in medical information management and EMR system functionality. Through verification, it was implemented to promote future development of the certification system and long-term development of the electronic mandatory record certification system. A total of 1,189 respondents were used for final analysis using structured questionnaires, and in particular, differences in recognition of certification systems and system functionality after EMR certification were verified by conducting average analysis and ANOVA. As a result of analysis, the electronic mandatory record certification system was confirmed to affect positive work changes and perceptions on medical institution workers, and after certification of the electronic mandatory record system, it showed operational effects in many ways. Based on the results of this study in the future, communication follow-up research is needed.

• Proceedings of the Korea Contents Association Conference
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• 2016.05a
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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".

• Journal of radiological science and technology
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• v.44 no.5
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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.

• Journal of Digital Convergence
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• v.13 no.7
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• pp.229-238
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• 2015

This research is aimed to develop a National competency standards(NCS) as a method of job standardization, and then to be applicated as a baseline data on overall university curriculum by using the NCS. Study period is from June 21, 2014 to November 30, 2014. To accomplish the aims, a pool of researchers and experts like as industrial site experts, education training experts, and job analysis specialists was formed. Job title to be conducted in medical record is defined as medical information management and NCS was developed through deducing 12 competency unit, 43 competency unit elementary and competency unit each career during lifelong. And finally the developed standards proposal was completed to be NCS after verification by on-the-spot specialists.

• Journal of Digital Convergence
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• v.15 no.10
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• pp.377-386
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• 2017

This study has developed a medical information management educational program that can improve the management ability of medical information. The educational medical information management program was developed for 8mnths uing VB. The database utilized the ACCESS Database, which allows learners to easily understand and understand the structure of the data. The learners enter data in the discharge analysis and the cancer registration program and the incomplete program after analyze the medical records. After entering and saving data, medical information management programs can be used to understand and analyze the structure of the database to generate medical information. The educational programs can improve the ability of learners to manage medical information by extracting the necessary data from the database directly through SQL and creating various medical information. However, although the medical information management program is an educational program, there is no evaluation system for the learners program operation. Accordingly, the next studies should develop the assessment system of the medical information management program for learners evaluation.

• Proceedings of the Korea Information Processing Society Conference
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• 2011.04a
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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.