• Title/Summary/Keyword: Medical record review

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Design of SPMR using URN based UCI with RFID (RFID와 UCI 기반의 URN을 활용한 SPMR 설계)

  • Jang, Doc-Sung
    • Journal of the Korea Society of Computer and Information
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    • v.12 no.2 s.46
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    • pp.291-297
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    • 2007
  • Linking patient's medical records throughout country is required to get patient's accurate information which is helpful for doctor to diagnosis patient's symptoms more exactly. With shortening of time and preventing of retest, patient can be survived or alleviate suffering. Purpose of this paper is to design combined identification system linking patient's RFID card with medical digitalized Chart to share patient's information between the hospitals. With research and review of pre-studied related identification system, standardization, and UCI-RFID linkage study, SPMR(sharing patient's medical record) has been designed for doctors to make a medical treatment properly at the right time and alleviate patient's pain. SPMR(sharing patient's medical record) which will take information needed and pay for information usage to related hospitals has been designed for doctors to make a medical treatment properly at the right time and alleviate patient's pain.

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A review on disease records of King-Injo of Chosun Dynasty - based on the records from The Daily Records of Royal Secretariat of Chosun Dynasty - (조선 인조(仁祖)의 질병기록에 대한 고찰 - 승정원일기 기록을 중심으로 -)

  • Kim, Hyuk-Kyu;Kim, Nam-Il;Kang, Do-Hyun;Cha, Wung-Seok
    • The Journal of Korean Medical History
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    • v.25 no.1
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    • pp.23-41
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    • 2012
  • 'The Daily Records of Royal Secretariat of Chosun Dynasty' is a record created in Seung-jeong-won, a secretariat for kings of Chosun, and is a government record which holds conversations between kings and their vassals as it is. General affairs in terms of the royal family and national administration are recorded, but what is more important is the records on diseases of kings and how they were treated. This study is to look into diseases from which King Injo(1959-1649) had suffered based on the records written during the time of his reign, which was from 1623 to 1649. Also, the "curse incident" and the death of prince Sohyeon, son of King Injo, both of which had significant influence on the health of the king, were reviewed in relation to the disease records.

Trends and Characteristics of Patients Who Have Been Received the Physical Therapy of Korean Medicine at an University Hospital: A Retrospective Medical Chart Review (일개 대학병원 내 한방물리요법을 받은 환자들의 후향적 의무기록 분석)

  • Hwang, Eui-Hyoung;Lee, Hyeon-Yeop;Heo, Kwang-Ho;Cho, Hyun-Woo;Hwang, Man-Seok;Shin, Mi-Suk;Kim, Jeong-Hwa;Park, Seong-Ha;Shin, Byung-Cheul
    • Journal of Korean Medicine Rehabilitation
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    • v.24 no.1
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    • pp.55-63
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    • 2014
  • Objectives The aim of this study was to offer the fundamental data for the physical therapies of Korean medicine through analyse the database of one university hospital. Methods As this study was retrospective analysis, following items were selected and analysed in the electronic medical record (EMR) database. (1) sex, (2) inpatient or outpatient, (3) medical department, (4) diagnosis, (5) kind of insurance. Results Although all kind of physical therapies were used, interferential current therapy (ICT) was the most used physical therapy. And department of rehabilitation medicine of Korean medicine prescribed physical therapies most among the 8 specialty departments. As physical therapies were used in various kinds of diseases, they were especially used in musculoskeletal diseases and nervous system diseases. Conclusions The analysis of actual condition of using physical therapies in a real clinical setting of Korean medicine could be a useful fundamental data for the application of modernized physical therapies.

Association between Electronic Medical Record System Adoption and Healthcare Information Technology Infrastructure

  • Lee, Youn-Tae;Park, Young-Taek;Park, Jae-Sung;Yi, Byoung-Kee
    • Healthcare Informatics Research
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    • v.24 no.4
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    • pp.327-334
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    • 2018
  • Objectives: The objective of this study was to investigate the relationship between the level of Electronic Medical Record (EMR) system adoption and healthcare information technology (IT) infrastructure. Methods: Both survey and various healthcare administrative datasets in Korea were used. The survey was conducted during the period from June 13 to September 25, 2017. The chief information officers of hospitals were respondents. Among them, 257 general hospitals and 273 small hospitals were analyzed. A logistic regression analysis was conducted using the SAS program. Results: The odds of having full EMR systems in general hospitals statistically significantly increased as the number of IT department staff members increased (odds ratio [OR] = 1.058, confidence interval [CI], 1.003-1.115; p = 0.038). The odds of having full EMR systems was significantly higher for small hospitals that had an IT department than those of small hospitals with no IT department (OR = 1.325; CI, 1.150-1.525; p < 0.001). Full EMR system adoption had a positive relationship with IT infrastructure in both general hospitals and small hospitals, which was statistically significant in small hospitals. The odds of having full EMR systems for small hospitals increased as IT infrastructure increased after controlling the covariates (OR = 1.527; CI, 1.317-4.135; p = 0.004). Conclusions: This study verified that full EMR adoption was closely associated with IT infrastructure, such as organizational structure, human resources, and various IT subsystems. This finding suggests that political support related to these areas is indeed necessary for the fast dispersion of EMR systems into the healthcare industry.

The Efficient Methods of Population-based Cancer Registration in Daegu City (대구지역 암등록사업의 효율적 수행방안)

  • Jin, Dae-Gu;Chun, Byung-Yeol;Ahn, Soon-Ki;Kim, Jong-Yeon;Kam, Sin
    • Journal of Preventive Medicine and Public Health
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    • v.35 no.4
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    • pp.322-330
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    • 2002
  • Objective: This study was conducted to automatically improve the completeness and validity of the Daegu Cancer Registry, using cross record linkage of many data sources, and to develop a computerized patient enrollment system for efficient communication among cancer researchers via the internet. Method: We analyzed 10,229 cancer patients who were reported in the National Cancer Registry, and from pathological reports, health insurance cancer claims lists, cancer patient records at hospital information centers and death certificates from the Korea National Statistical Office. Result: We confirmed 4,624 cancer patients and found 897 of new cases from a review of medical chart. The new cases were detected efficiently using cross record linkage. We developed a computerized patient enrollment system, based on a client-sewer model, for the input of cancer patients, and then developed a web-based reporting homepage and patient enrollment system for the internet. Conclusion: This system could manage cancer databases systematically, and could be given to other researchers as a basic database.

A Comparison of Efficiency between Computerized Nursing Records and the Paper-based Nursing Records - focus on patients with a stroke - (전산간호기록과 서면간호기록의 효율성에 관한 비교연구 - 급성 뇌졸중 환자의 간호기록 중심으로 -)

  • Sung Young-Hye;Cho Myung-Sook;Choi Bok-Yeon;Jang Mi-Ra
    • Journal of Korean Academy of Fundamentals of Nursing
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    • v.13 no.1
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    • pp.24-32
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    • 2006
  • Purpose: This study was a comparative review of the computerized nursing records and paper-based nursing records to examine effects of a nursing process documentation system focusing on patients who have had stroke. Method: First, the researchers collected all the foci from the computerized records and the paper-based records. They selected ten nursing foci, used frequently in both groups and analyzed the number of foci per patient, appropriateness of foci, the number of nursing activities per nursing focus and whether outcomes were described or not in the nursing record. Results: There was fewer errors in nursing diagnosis selection, and a larger number of activities in the records than trle paper based ones. Also, there was a better description of the nursing outcomes in the computerized records. Conclusion: This study suggests that the computerized nursing records is significantly effective in increasing accuracy of the nursing care plan and quality of the nursing record.

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Risk Factors for Nosocomial Urinary Tract Infection in the Intensive Care Unit with a Positive Urine Culture and Foley Catheterization (소변 미생물 균주 양성인 중환자실 유치도뇨관 환자의 병원성 요로감염 발생과 관련요인)

  • Yu, Seong-Mi;Park, Kyung-Yeon
    • Journal of Korean Academy of Nursing
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    • v.37 no.7
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    • pp.1149-1158
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    • 2007
  • Purpose: The purpose of this study was to identify the risk factors for a nosocomial urinary tract infection in intensive care units with a foley catheterization which showed a positive urine culture. Method: Three-hundred eighty-seven patients were included in the study. A retrospective review of the electrical medical record system's databases and medical record sheets in hospitalized patients from January 2003 to December 2003 was used. The collected data was analyzed by descriptive statistics, t-test, chi-square test and logistic regression analysis. Result: The frequency of the participants' nosocomial urinary tract infection was 72.9%. Significant risk factors for a nosocomial urinary tract infection were 'age', 'place of catheter insertion', 'frequency of catheter change', and 'duration of catheterization'. These variables explained 18.4% of variance in the experience of nosocomial urinary tract infection in intensive care units with foley catheterization. Conclusion: Medical personnel can decrease the incidence of a nosocomial urinary tract infection by recognizing and paying attention to the duration of catheterization, frequency of catheter change, and place of catheter insertion. As a result, specific and scrupulous strategies should be developed to reflect these factors for decreasing nosocomial urinary tract infections.

The Variation of HbA1c Examination Performance Rates among Diabetic Patients Using Ambulatory Care in South Korea (우리나라 외래서비스 이용 당뇨환자의 특성에 따른 당화혈색소(HbA1c)검사 시행률 변이 분석)

  • Hong, Jae-Seok;Kang, Hee-Chung;Kim, Jai-Yong
    • Health Policy and Management
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    • v.19 no.1
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    • pp.49-61
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    • 2009
  • Background: The appropriate management of diabetes mellitus(DM) can help reduce its relapse and economic burden, but the level of management of DM in Korea is reported to be insufficient. This study aims to identify the management level of DM by figuring out the HbA1c examination performance rate of the diabetics and analyzing the variation according to the characteristic of a diabetic. Methods: This study used the Korean National Health Insurance Database which includes E10-14(ICD-10 code) as a primary or secondary disease as of 2006. Study population is 1,892,062 diabetics excluding 393,784 patients with the first attack of DM in 2006, 33,440 diabetics who died in 2006, and 21,299 patients with DM having no record of ambulatory care among the 2,340,585 DM patients in total. Results: The HbA1c examination performance rate of all DM patients in our country is estimated to be 41.5% as of 2006 and shows variation according to the characteristic of individual DM patients. The highest performance odds was shown by the patients who were below 19 of age, insured for health insurance, attended more than 3 ambulatory care providers, made ambulatory care visits more than 10 times annually, attended a specialized general hospital as their main attending medical institution, had a record of hospitalization or had co-morbidity. Conclusion: This study propose that is necessary to make politic preparations for the appropriate management of diabetes at a national level, and particularly, the patients with advanced age, the ones dependent on Medical Aid, and the ones using hospitals or clinics, whose appropriate management seems vulnerable, demand a careful management.

Efficacy and Safety of Gabapentin in the Treatment of Chronic Cough: A Systematic Review

  • Shi, Guanglin;Shen, Qin;Zhang, Caixin;Ma, Jun;Mohammed, Anaz;Zhao, Huan
    • Tuberculosis and Respiratory Diseases
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    • v.81 no.3
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    • pp.167-174
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    • 2018
  • Despite recent clinical guidelines, the optimal therapeutic strategy for the management of refractory chronic cough is still a challenge. The present systematic review was designed to assess the evidence for efficacy and safety of gabapentin in the treatment of chronic cough. A systematic search of PubMed, Embase, Cochrane Library databases, and publications cited in bibliographies was performed. Articles were searched by two reviewers with a priori criteria for study selection. Seven relevant articles were identified, including two randomized controlled trials, one prospective case-series designed with consecutive patients, one retrospective case series of consecutive patients, one retrospective case series with unknown consecutive status, and two case reports comprising six and two patients, respectively. Improvements were detected in cough-specific quality of life (Leicester Cough Questionnaire score) and cough severity (visual analogue scale score) following gabapentin treatment in randomized controlled trials. The results of prospective case-series showed that the rate of overall improvement of cough and sensory neuropathy with gabapentin was 68%. Gabapentin treatment of patients with chronic cough showed superior efficacy and a good safety record compared with placebo or standard medications. Additional randomized and controlled trials are needed.

Nursing Time Use in a Newborn Intensive Care Unit (NICU) (신생아중환자실 간호사의 간호업무량 분석)

  • Jun, Eun-Kyoung
    • Journal of Korean Academy of Nursing Administration
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    • v.6 no.1
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    • pp.55-81
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    • 2000
  • This study examined nursing care in a Newborn Intensive Care Unit (NICU) by reviewing nursing activities for the newborns. Through direct observation, time used for nursing care according to the nursing activity, shift, day of the week, and position of the nurses was measured. This study was done on November 15, 21, 24, 1999 at a university medical center hospital and included eight nurses and 179 newborns as the study subjects. The data were collected from the medical records, and by using a nursing activity record for the NICU, and a nursing activity time record for the NICU. The first step in the data collection process was to develop a list of nursing activities which was done through a literature review, examination of medical affairs and duty records. Content validity was measured by a panel of three professors who were experienced clinicians. In the second step two pre-training sessions were held with three sophomore student nurses who then measured the time for each nursing activity using a stopwatch. The data were analyzed using frequencies for nursing activities, averages, percentages and ANOVA for differences between shift and between days of the week, and percentages and t-test for differences according to position of the nurse. The results are as follows: 1) The total number of activities was 156, direct or indirect nursing activities. Direct nursing activity classified according to physical, educational, emotional/social/economic/spiritual needs. There were 109 direct nursing activities in 16 fields. 2) The order of nursing activities, according to time required, was record keeping, nutritional care, measurement/observation, medication, hygiene care, examination and specimen collection, and checking supplies, and according to frequency, measurement/ examination, record keeping, nutrition care, hygiene care, elimination care and medication. 3) According to shift, direct care during the night shift at 313.4 minutes was the longest time and indirect nursing care during the night shift at 252.2 minutes was the highest time. 4) For days of the week, Monday had the highest time for direct care 275.8 minutes (34.6%) and Wednessday had the highest time for indirect nursing care 269.6 minutes (36.1%). 5) For nursing time according to position of nurse, general nurses had the highest for direct care (330.7 minutes), nurse managers for indirect nursing activities (239.0 minutes) and general nurses for individual private time (63.9 minutes). The results of this study show that the major nursing time consuming activities included record keeping, nutrition care and measurement/examination. For newborns, time needs to be allowed for care to be sensitive, sophisticated and specialized rather than concentrated on indirect nursing tasks such as record keeping. Therefore, it is imperative to develop computerized systems that support a systematic approach to record keeping which is more efficient. Moreover, nursing needs according to shift, day or position of nurse can be utilized in assessing nursing resources through a computerized process.

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