• 의료ㆍ복지 건축 : 한국의료복지건축학회 논문집
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• 제2권3호
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• pp.35-43
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• 1996

The paper chart of medical record had been used as an important medium of the medical information in the medical recording department. This chart has not dealt with the development of information industry and the change of use of medical record in several decades. This study is to show the data which is helpful for the current spacial situation of medical recording in Korea and understand problems to reconsider the medical recording department of hospital architectural plan. In addition, this study is to look for the spacial changes by computerizing of medical recording and its special confrontation and the prospect for the future medical recording department which is going to work as a medical information center.

• 한국병원경영학회지
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• 제8권2호
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• pp.111-129
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• 2003

This study discusses the direction of legislation to strengthen the legal protection of medical records privacy in information age. The legislation trends on privacy protection of medical records in European Union and United States are analysed and the current law and regulation of Korea on medical records are compared. The issues discussed include the ownership of medical records, the patient's right of access to medical records, medical information publication for other than treatment or insurance processing use, confidentiality responsibility of provider organizations, medical information management in provider organizations, penalty for the unlawful use of patient information. This study concludes that the patients' right on medical record and provider organization's responsibility in processing patient information should be strengthened in order to protect patients' privacy and to conform to the international standard on medical record protection in the information age.

• 한국콘텐츠학회논문지
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• 제5권6호
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• pp.120-128
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• 2005

전자정보의 기밀성과 무결성을 유지하는 가장 안전한 보안방법 중의 하나가 공인전자서명이다. 이를 의료분야에 적용하기 위하여 본 논문에서는 전자서명법과 의료법에 기반을 둔 전자의무기록에 대한 공인 전자서명의 구체적인 적용 지침을 개발하였다. 개발된 지침은 공인전자서명의 주체 및 시점, 공인인증서의 유효성 확인, 공인전자서명의 관리 책임, 전자의무기록의 보관 및 관리에 관한 적용 지침과 관련 해설을 그 내용으로 하고 있다. 향후에는 이 지침을 토대로 의료기관과 관련 업체에서 전자의무기록 시스템 구축 시 실제 활용할 수 있는 예시들을 개발하고자 한다. 이는 전자의무기록의 도입을 용이하게 하고, 그 보급을 촉진할 뿐 아니라 의료기관과 관련 업체들이 겪고 있는 애로사항을 해소하는데 크게 기여하게 될 것이다.

• Journal of information and communication convergence engineering
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• 제18권4호
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• pp.260-266
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• 2020

This study presents the categorical structure for ther epresentation of a 3D human body position system in the WD stage after NP approval by the International Organization for Standardization (ISO), analyzes the needs of electronic medical record users and establishes future implementation plans for expanding its use in Korea. Research was conducted on the needs of doctors, nurses, health and medical information managers, and radiology departments, which are the main stakeholders of electronic medical records. The overall requirements for electronic medical records were derived from the results, and the requirements for each stage of use of electronic medical records were analyzed. Based on the results of the study, the study proposes plans to expand the use of the categorical structure for the representation of the 3D human body position system, and also aims to establish a standard system for health and medical terminology in Korea and contribute to the development of health and medical information standards through international standardization.

• 대한한의학회지
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• 제20권4호
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• pp.29-38
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• 2000

In China, there are many books of medical record since Mingaileian which was written by Guan Jiang and Ying-Xiu Jiang in 1552. On the other hand, in Korea there are few medical records and the study of them is not widespread. The purpose of this study is promoting the study on the Korean medical records by the investigation on the medical records in the Euimunbogam which was written by Myoung-Shin Zhu in 1724. The book is composed of 263 medical records. Among them, 215 records are quoted from Chinese medical books and 48 records are original. There are some quoted books which were written after Dongeuibogam, such as Shoushibaoyuan, Zhingyuequanshu etc.

• 한국정보처리학회:학술대회논문집
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• 한국정보처리학회 2010년도 춘계학술발표대회
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• pp.352-352
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• 2010

It is difficult to settle the well-designed local terminology for imaging report in the hospital information system (HIS). One of the major reasons is the local terminology with poor contents have been used in the hospital. Thus, we mapped the locally used terms in nuclear medicine imaging report to the SNOMED-CT, which had been widely used in the electronic medical record system, for implementation of hospital information system. Preliminary construction of terminology dictionary was done by mapping of local terms to SNOMED-CT and LexCare Suite. Further study may be warranted.

• Clinical and Experimental Pediatrics
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• 제51권9호
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• pp.907-910
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• 2008

Recently we published new edition of 'child & Adolescent health record book' considering easy usability and introduction of new vaccines. This record book has essential and important contents for caring our children and adolescents. Currently many people use various vaccination record books with wrong and poor contents. We suggest the campaign that every pediatrician must give our well made record book to these people. This campaign can give their children an opportunity for proper vaccination and medical checkup. Ultimately through this campaign, the role and importance of pediatrician in the fields of vaccination and bring up children and adolescents will be recognized. We trust that the better record book can be made with continuous interest and active advice of all Korean Pediatric Society members about the contents and usability of this book.

• 한국의료질향상학회지
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• 제8권2호
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• pp.208-217
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• 2001

Background : The objective of this study is proving the basic data for developing a management system for the discharges against medical advice(AMA) by identifying the characteristics of the AMA patients of an university hospital for 10 years. Methods : By using discharge abstract data base, we divided the total discharges(435,254) into two groups, discharge against medical advice and discharge with discharge order. We confirmed the characteristics of AMA group by analyzing discharge abstract data of the both groups by SAS software V6.12 and $x^2$ test. Medical records of AMA patients in the year 2000 were reviewed to identify the reasons for AMA which we couldn't extract from discharge abstract DB. Result : The total number of AMA for 10 years were 9,358(2.15%) and the AMA rate has been continuously decreased for 10 years. Male, admission through emergency room, discharges admission via other hospital, patients without operation during hospitalization, discharges in hopeless or not improved condition showed higher AMA rate. The AMA rate was higher as the age of the patients was higher, and the average length of stay was longer in AMA patients than in those with discharge order. The AMA rate in psychiatry was highest(14.3%) and it was higher in surgery departments than those of medical or other sections. The AMA rate varied by attending physicians even in the same department and it was statistically significant. Patients with the principal diagnosis of "medical observation and evaluation for suspected diseases" showed the highest AMA rate(15.5%), and that of schizophrenia or psychosis was the nest. One hundred twenty-one patients(19.5%) out of 622 AMA in 2000 discharged against medical advice for transfer to order health care facilities. Among them 71 patients(58.7%) discharged with their medical care information, such as copies of medical record, medical certificates, summaries, etc. Written oath of the patients discharged AMA was filed in their medical records in 466 cases(74.9%) although some of them were incomplete. Conclusion : Characteristics of AMA discharge could be used as the basic data in developing a system to manage the patients who have risk factors to leave the hospital against medical advice. By reducing number of patients leaving the hospital against medical advice we can increase satisfaction of medical providers and consumers.

• 한국의료질향상학회지
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• 제10권2호
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• pp.204-215
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• 2003

Background : ICD-10 Classification, which is used domestically as well as internationally, has limited use in the clinical practice since it is developed for at disease statistics and epidemiology. Therefore, the purposes of this study were to improve the quality of diagnosis by constructing a new disease classification based on the diagnoses doctors currently make in the clinical setting and connecting this classification with OCS and EMR, and to meet the demands of doctors for high quality medical study data in medical research. Methods : The specialists in each ophthalmic subfield collected clinical diagnoses and abbreviations based on the ophthalmology textbooks and confirmed the classifications. Total number of clinical diagnoses collected was totaled 672, for which ideal diagnoses had been selected and a new model of disease classification model in connection with ICD-10 was constructed. The constructed classification of clinical diagnoses consisted of six steps: the first step was the classification by ophthalmic subspecialty field; the second to fifth steps were the detailed classification by each specialty field; the sixth step was the classification by site. Results : After introducing the new disease classification, research on the use and a pre-post comparison was conducted. The result from the research on the use of the clinical diagnoses in inpatient and outpatient care has shown a gradually increasing tendency. From the pre-post comparison of EMR discharge summary diagnoses, the result demonstrated that the diagnosis was stated correctly and in detail. Since the diagnosis was stated correctly, code classification became correct as well, which makes it possible to construct high quality medical DB. Conclusion : This construction of clinical diagnoses provides the medical team with high quality medical information. It is also expected to increase the accuracy and efficiency of service in the department of medical record and department of insurance investigation. In the future, if hospitals wish to construct a classification of clinical diagnosis and a standard proposal of clinical diagnosis is presented by a medical society, the standardization of diagnosis seems to be possible.

• 한국멀티미디어학회논문지
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• 제12권8호
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• pp.1172-1181
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• 2009

전자의무기록(Electronic Medical Record, EMR)은 모든 검사 과정이 텍스트 기반의 데이터 형태로 저장되는 의료 분야의 의무기록 시스템을 의미한다. 그러나 국내의 전자의무기록 시스템은 각 의료기관마다 고유한 의료정보검사코드 형태를 이용하여 기록하는 방식으로 정보를 저장하기 때문에 병원 간의 의료검사 기록 형태들의 공유, 해석, 분석에 많은 문제점들을 가진다. 위의 문제들을 해결하기 위하여 표준화 되어 있지 않은 병원들의 검사코드들을 LOINC (Logical Observation Identifiers Names and Code)로 표준화하려는 연구들이 많다. 현재까지의 연구들은 로컬 의료정보검사코드를 수동으로 LOINC로 변환하는 방법이 연구되었다. 또한 대용량 의학 정보들을 다루기에 적절하지 않은 파일 기반에서 코드들을 관리하는 연구들이 이루어져왔다. 기존의 문제점을 해결하기 위하여 본 논문에서는 의료 용어 표준화 알고리즘을 제안하고, 구현하여 해결하였다. 또한, 대표적인 상용시스템이 가졌던 문제점인 검색어를 의사가 직접 생성해야 했던 부분을 LOINC 의 여섯 가지 자동 속성 추출 및 검색어 자동 생성 기능을 구현하여 해결하였다. 또한, 기존의 시스템들이 고려하지 않았던 대용량 데이터의 매핑 부분을 파일 시스템 기반이 아닌 데이터베이스 기반 검색 프레임웍을 구축하였다.