• 한국병원경영학회지
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• 제15권1호
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• pp.1-12
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• 2010

This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor's admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor's admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor's admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking (p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.

• 의료법학
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• 제11권2호
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• pp.309-335
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• 2010

This study is a paper reviewed legal status of medical personnel and issues of law on recently discovered medical records. As the increase of medical personnel who have gone through the administrative disposal in regards to the medical records, it is needed to examine the legal issue or dispute on the medical records under the current law. Medical records are the statement on patient's medical conditions made by the medical personnel. This records are used as important source for patient's further treatment. This becomes the communication route between the patients and the other medical personnel, and it provides the patients a right to find out their medical information. According to the Medical Service Act (Article 21), a medical personnel shall prepare respectively a record book of medical examination and treatment. And medical personnel shall make a signature. Furthermore, the medical personnel or the opener of the medical institutions must preserve the record book (including an electronic medical record). Meanwhile, the issues of a ban on false entry, additional record, revision or manipulation on the medical record have been recently on the rise. This paper briefly examined the major issues in regards to the medical records. It especially clarified the legal duty on medical records and its major-contentious-issues. At the same time, it pointed out the problems of the unreasonable over interpretation of the law. Furthermore, this suggested the guidelines for the further discussion and review.

• 대한한의학원전학회지
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• 제31권2호
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• pp.105-126
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• 2018

Objectives : This paper aims to study the educational meaning of Shanghanjiushilun in Shanghanlun education focusing on purgation therapy. Methods : Clinical medical records in Shanghanjiushilun associated with purgation therapy were chosen, analyzed and its educational meaning was studied. Results & Conclusions : 1. Xushuwei's clinical medical records are significant as it helps the readers think of various disease mechanisms by not omitting mistreatment of the other doctors. 2. Xushuwei's clinical medical records are significant as it helps the readers become aware of the importance of a differential diagnosis through questions and answers. 3. Xushuwei's clinical medical records are significant as it helps the readers avoid looking at one side of things through taking a comprehensive look at disease syndrome in various fields. 4. Xushuwei's clinical medical records are significant as it helps the readers escape unreasonableness by suggesting practical aspect managing the patient. 5. Xushuwei's clinical medical records are significant as it enable the readers to draw a new disease mechanism interpretation by making up for explanations of the pathogenesis quoting medical classics. 6. Consequently, in learning and teaching Shanghanlun, Xushuwei's clinical medical records have enough educational meaning as mentioned above.

• 한국기록관리학회지
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• 제20권3호
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• pp.55-76
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• 2020

우리나라 대부분의 의료기관이 전자의무기록을 도입하고 있지만, 의료기관이 폐업했을 경우의 기록물 관리 및 보존에 있어서 많은 맹점이 존재한다. 폐업 의료기관의 기록은 적법한 절차에 따라 체계적으로 관리될 필요가 있음에도 불구하고 보건소로 기록을 이관하는 폐업 의료기관의 수가 현저히 적고, 전자의무기록을 사용하는 의료기관마다 사용하는 시스템 및 서식이 상이하기 때문에 이관을 받는 보건소에서도 해당 기록을 열람조차 하지 못하는 경우가 많다. 또한, 보건소의 현실과 전자의무기록이라는 특수성에 부합한 관리기준 및 지침 또한 부재한 상황이다. 최근 폐업 의료기관의 의료기록에 대한 보건소의 보관책임 강화 법안이 통과함에 따라 본 연구에서는 관할 보건소의 효율적인 기록물 관리를 위한 방안 마련에 주목하였다. 이를 위해 관계 법령을 살펴보고 관리·보존이 미흡한 폐업 의료기관 전자의무기록 관리 현황을 파악하기 위한 문헌조사를 비롯한 정보공개청구 및 전화인터뷰 등의 조사를 실시하였으며, 그 문제점을 분석하여 제도적·기술적·행정적인 측면에서의 개선방안을 제안하였다.

• 동의신경정신과학회지
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• 제27권2호
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• pp.43-55
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• 2016

Objectives The aim of this systemic review was to summarize medical records of Korean medicine based psychotherapy and investigate its therapeutic mechanism.Methods We searched articles on Korean neuropsychiatry in Korean databases. Subsequently, we selected and analyzed medical records on Korean medicine based-psychotherapy that met inclusion criteria.Results Fifty-five medical records were included. They were classified into the following 5 categories. Five minds mutual restriction therapy in 19 medical records; counseling and persuading therapy in 12 medical records; moving essence and changing Qi therapy in 10 medical records; Kyungjapyungji psychotherapy in 2 medical records; and suggestion psychotherapy in 11 medical records.Conclusions The results indicated that emotion is mainly used for cure. Buddhism affects Korean medicine based psychotherapy. Korean medicine based psychotherapy corresponds to western psychotherapy such as short-term dynamic psychotherapy (STDP), supportive psychotherapy, cognitive therapy, behavior therapy, and guided imagery.

• Advances in Traditional Medicine
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• 제7권2호
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• pp.103-113
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• 2007

This study is a report on recently discovered medical records based on traditional medicine in the 1900s. First, the contents of the records and their significance are described in detail. Next, a simple example of the research follows, in order to explain the medical and historical significance the records contain and to answer the question of how this historical document can contribute to future medical and historical studies. The documents dealt with in this study, the Chunggang Medical Records, are medical records compiled by a Korean doctor of oriental medicine by the name of Younghun Kim who practiced in the center of Seoul for a period of over 60 years. The records, which eventually amounted to over 1,500 books, were made known to the academic world when the descendents recently donated them to Kyunghee University. The reason these medical records attract so much attention from academic circles, even though they are the work of one individual, is that they contain abundant information on general public medical health at the time, in addition to the fact that Kim Younghun was a well known figure among Oriental Medicine doctors in Korea. The medical records start in 1915 and continue until Kim Younhun's death in 1974, though they have some damaged or missing parts. Kim's medical records are a gold mine not only for scholars studying the medical history of the early 1900s, but also for doctors trying to emulate the techniques embedded in a great predecessor's medical practice.

• 동의생리병리학회지
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• 제19권6호
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• pp.1457-1470
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• 2005

The Medical records (醫案) are very important materials in studying the developmental process of traditional Korean medicine. In this study, we investigated the medical records which are described in Naekyung-pyun(內景篇) of Dongeuibogam(東醫寶鑑), the most famous medical literature in Korean. There are 50 medical records in Naekyung-pyun and all of these records are cited from 12 Chinese medical literatures. The medical records were mainly cited from medical literatures written in Jin-Yuan(金元) and Ming(明) dynasty such as Yixuegangmu(醫學綱目) and Danxizanyao(丹溪纂要), although most records were written by medical scholars in Jin-Yuan(金元) dynasty, including Zhudanxi(朱丹溪) and Zhangzihe(張子和). Most of records were omitted and/or modified reflecting the Purpose of editors of Dongeuibogam. In addition, medical essay(醫論) was changed into medical record in some cases. The authors of the records used oral medication, acupuncture-moxa, psychological treatment and surgical manners. And in some cases of only having principal of treatment, the editors newly added the herbal prescription. The further study on medical records in Korean traditional medicinal literatures, would reveal the developmental progress of Korean medicine and inform more actual proof on medical condition.

• 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.

• 대한한의학원전학회지
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• 제31권1호
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• pp.113-125
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• 2018

Objectives : The purpose of this paper is to investigate the educational meaning of Shanghanjiushilun in Shanghanlun education. Methods : The formal characteristics in medical records were compared between Shanghanjiushilun and the other 5 kinds of medical record books and the educational meaning was drawn by analysing medical records of Shanghanjiushilun a little more deeply. Resultss & Conclusions : 1. In a formal aspect, although Shanghanjiushilun is inferior to Liuduzhou's Clinical Medical Records Selection, it has merits in that it explains through quoting medical literature. 2. Xushuwei explained treatment based on syndrome differentiation in the new point of view in Shanghanjiushilun. 3. Through Shanghanjiushilun medical records Xushuwei's work to explain treatment based on syndrome differentiation in Shanghanlun in the new perspective is an effort to read medical classics to keep up with the times and has sufficient educational significance.

• 한국기록관리학회지
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• 제13권1호
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• pp.107-134
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• 2013

많은 병원이 '디지털 병원'을 실현하기 위해 전자의무기록을 도입하고 있지만, 기록물 관리 및 보존에 있어서 많은 문제점이 존재한다. 전자의무기록 시스템은 병원마다 서식과 용어 등이 상이하며 의무기록 생산시스템과 의무기록관리의 표준이 없는 상황에서 OCS, PACS, EMR 등의 시스템이 독립적으로 운영됨에 따른 많은 문제점이 나타나고 있다. 의무기록을 효율적으로 관리하기 위해서는 분산 관리되고 있는 종이의무기록과 전자의무기록을 통합관리 할 필요가 있다. 따라서 본 연구에서는 의무기록관리 현황과 문제점을 알아보기 위해 J 대학병원을 대상으로 의무기록관리 현황에 대한 분석과 함께, ISO 15489의 기록관리과정을 기반으로 의무기록관리를 위한 개선방안과 통합의무기록관리시스템을 통한 의무기록관리 프로세스를 제안하였다.