• 정보관리학회지
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• 제29권3호
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• pp.257-285
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• 2012

전자의무기록시스템(EMR)이 도입되고 의무기록 이해당사자들의 요구가 변화함에 따라 우리나라 병원의 의무기록 생산 및 관리 환경이 급변하고 있다. 그동안 정보관리의 차원에서만 다루던 의무기록을 기록관리의 관점에서 살펴봄으로써 병원의무기록관리에 의미있는 시사점을 도출할 수 있을 것이다. 이 연구에서는 기록관리의 기본 원칙을 다루고 있는 KS X ISO 15489 표준을 병원의 의무기록관리에 적용하여 현황을 분석하고 개선과제를 도출하고자 하였다. 이를 위해 첫째, 표준에서 제시하고 있는 기록관리과정 별로 의무기록관리에 적용할 기준원칙을 작성하였는데, 획득, 등록, 분류, 저장, 접근, 추적, 처분 등 기록관리 7단계에서 총 22개의 기준원칙을 선정하였다. 둘째, 서울 소재 의과대학 부속병원인 Y병원을 대상으로 의무기록관리 현황을 평가하였다. Y병원 의무기록관리팀 부서장을 면담하여 각 기준원칙별로 준수, 부분 준수, 미흡, 미준수의 4가지 수준으로 현황을 평가하였다. 셋째, 기준원칙을 충실히 준수하지 못하고 있는 접근, 추전, 처분 단계부분을 중심으로 의무기록관리의 개선방안을 제시하였다. 이 연구를 시작으로 하여 향후 기록관리 메타데이터표준, 기록경영시스템표준, 기록관리시스템표준 등도 병원의 의무기록관리에 적용함으로서 유용한 시사점을 얻을 수 있을 것으로 기대한다.

• 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.

• 한국의사학회지
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• 제18권2호
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• pp.189-195
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• 2005

Medical Records are the clinical chronicles of Korean Medicine. It not only has value as historical documentation, but also has value in clinical use. If studies of medical records that contain specific methods for tackling diseases are accompanied, it will be easier to clearly see the internal development process of Korean Medical History. This paper was written in order to achieve these goals by reporting the thoughts on the necessity and meaning of studying Medical Records.

• 동의생리병리학회지
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• 제22권1호
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• pp.1-12
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• 2008

This study is a report on the restoration process and future projects involving the restoration of the medical records from 1914 to 1974. Cheong-Gang Young-Hoon Kim was born in 1882 and passed away in 1974. His times were the times when Korean Traditional Medicine was being neglected due to the introduction of Western Medicine through Japan. During this time Young-Hoon Kim put much effort into the Korean Traditional Medicine Restoration Movement and left over 150,000 medical records while consistently examining patients. Currently, this data can be found at the College of Oriental Medicine, Kyunghee University and is being compiled into a database as a part of the 2007 Knowledge of Oriental Medicine Web Service Project. The Preface and Chapter 1 introduce the author and the contents of the Cheong-Gang Medical Records, and Chapter 2 briefly discusses the necessity of providing digitalization and modernization to the medical records. Chapter 3 discusses the preservation process of the original medical records, chapter 4 describes the process of restoring and providing web access to the contents of the medical records, and chapter 5describes the main purpose of the medical records as well as future projects and an outlook involving the Knowledge of Oriental Medicine Web Service Project.

• 한국산학기술학회논문지
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• 제9권3호
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• pp.787-793
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• 2008

본 연구는 대전광역시에 소재한 A대학교 병원 의무기록실에서 2006년 1월부터 2006년 3월까지의 3개월간 의무기록사본 발급 받은 환자 및 환자 보호자를 대상으로 사본발급특성을 구조방정식한 결과 "의무기록 사본 발급시간대"는 "의무기록 사본 발급 특성"에 대한 경로계수가 -0.01로 (-)의 직접 효과가 있었고, "일반적 특성"에 대한 경로계수가 0.86으로 정(+)의 직접 효과가 있었다. 이는 소비자의 권리의식의 향상과 각종 민간보험업계의 보험금 지급업무와 관련된 진료내용의 확인요구 등의 이유로 인하여 환자 본인, 보호자 및 보험회사 직원 등 다양한 대리인이 환자 개인의 진료기록에 대한 열람이나 사본교부를 요구한 결과로 사료된다. 이상과 같은 결과, 의무기록 관리에 있어서 사생활 보호(privacy)와 비밀 보호(confidentiality)는 가장 중요한 핵심으로 의무기록 저장 매체가 종이든 전자 매체든 관계없이 지켜져야 할 것으로 사료된다.

• 대한약침학회지
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• 제21권3호
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• pp.195-202
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• 2018

Objectives: The study was to survey use of electronic medical records in subjects of Korean medicine doctors working for Korean medicine organizations and to contemplate ways to develop utilization of electronic medical records. Methods: On August 2017, it conducted online self-reported survey on subjects of Korean medicine doctors at Korean hospitals and clinics who agreed to participate in the study. A total 40 doctors in hospital and 279 doctors in clinic were included. The surveyed contents include kinds of electronic chart, reason for not using electronic medical records and problems with creation of medical records. Results: It finds that 100% of those working at Korean medicine hospitals and 86.4% of those at Korean medicine clinics have used electronic medical records. Subjects answered the biggest reason for not using electronic medical records was inconvenience. The most serious problems with creation of electronic medical records at Korean medicine organizations found in the study include there was no method of creation of medical records and no standardized terminology for use in electronic medical records. Conclusion: For utilization of electronic medical records at Korean medicine organizations, standardization of terminology, development of EMR in favour of its users and development of strategy that motivates use of EMR are required.

• 대한한의학원전학회지
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• 제21권4호
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• pp.13-28
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• 2008

We have known that "Chimgudaeseong(鍼灸大成)" had been written by Yanggyeju(楊繼洲) in Ming(明) dynasty. And it had been the only text book of acupuncture & moxibustion for 300 years. This book is composed of 10 chapters dealing almost all the medical theories of that times. This book is so enormous that it is hard to understand essential ideas of author. The reading medical records is one of the best way to develop one's abilities of curing a disease without clinical practice. so we can't help dealing with medical records, because it is one of important method of understanding Oriental Medicine. On this study, we investigate a objective method on understanding medical records in "Chimgudaeseong(鍼灸大成)".

• 한국의사학회지
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• 제33권2호
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• pp.77-87
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• 2020

Objective : The Annals of the Joseon Dynasty is a primary historical record that has provided a great deal of information about what the Joseon Dynasty was like. However, as of yet, we know very little about the medical officers in Joseon dynasty, such as their government posts and official ranks. The purpose of this study is look in to the activities, government posts, and official ranks of the medical personnel by examining Yeongjosillok. Methods : First, I selected historical records containing '醫' in Yeongjosillok. Then, I organized medical officers' name by reading each record. I screened historical records in Yeongjosillok with their names to analyze their activities, government posts, and official ranks. When there was limited information available, I referred to The Daily Records of Royal Secretariat of Joseon Dynasty. Results : I found 262 historical records in Yeongjosillok containing '醫'. Then I found 26 people who served as medical officers in Yeongjosillok. Also, l found that 11 government posts and 7 official ranks were awarded to them throughout the 110 historical records in Yeongjosillok and The Daily Records of Royal Secretariat of Joseon Dynasty. Conclusion : Through this study, I was able to examine the detailed activities of unknown medical officers by studying the historical records in Yeongjosillok and The Daily Records of Royal Secretariat of Joseon Dynasty. Under the Joseon Dynasty's class-based society, the middle class had various restrictions. However, I found that medical officers that belonged to the middle class received exceptional treatment despite their social status.

• 한국의료질향상학회지
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• 제6권1_2호
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• pp.80-91
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• 1999

Background : With the CQI concepts, which emphasize doing the right things right the first time, we tried to enhance the timely completion of medical records by changing the review process from retrospective method to concurrent one. Methods : Against the current retrospective QA activity, Medical record administrator did the concurrent QA of the inpatient medical records with the deficiency sheets. One general surgery ward was chosen as a trial one. The deficiency rate of the medical records of the discharged patients was compared before and after the enforcement of the system. Job analysis of the medical record departments was done about four tertiary care hospitals located in Seoul to estimate the cost and the time consumed by current system. Results : There was a little improvement in the completion rate of the medical records after the trial. The new system was effective. And job analysis showed that much money and time were wasted by current retrospective feedback system. Conclusion : Though the result was not so satisfactory, it should be considered that this test was a voluntary one and the interns and residents were not forced to complete the medical records during this trial period. If there be any strong motivation to complete the medical record in time, this system is sure to be succeed. As the DRG system requires the concurrent review of the medical records to confirm severity of the patient's illness and to assure the timely discharge, it is desirable to enforce this method with the DRG system together. DRG coding and reducing deficiency rate of the medical records can be accomplished simultaneously.

• 대한예방한의학회지
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• 제18권3호
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• pp.11-21
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• 2014

The rapid development and distribution of information communication industry facilitates the changes of hospital administration, introducing EMR(Electronic Medical Record) instead of paper-based medical record in the medical field. The developed countries such as U.S. have established EMR system after in the middle of 1970s because the primary advantages of EMR is to store and handle vast amounts of records efficiently and increase the quality of health care. Most of health organizations in Korea also apply medical record system to their administration. As the result, they have accomplished a scientific administration system through the use of medical record to handle a variety of patient's information including patient's confidentiality and privacy such as family history, social status, income level, and so on. However, access to and the misuse of EMR causes illegal infringement of patient's information and finally it becomes a very serious medical issue. Potential leakage and misuse of records may seriously infringe patient's privacy rights. In this respect, the related agencies in the public and private sector have been making efforts to prevent patient's records leakages. Especially, the revision bill of Medical Law in 2002 establishes the ways on the security and standards of electronic records. However, it does not provide the proper guidelines which is applied to the rapid changes of the medical environment. One of the most priorities in the hospital administration is the production and maintenance of an accurate medical records fulfilled by medical recorders. Therefore, it is very important for health care providers to hire ethical-based medical recorders. But, unfortunately most of hospitals overlook the importance of their roles. All parts including government, physician and patient must have more concerns on the problems related to EMR. Therefore, this study aims to propose the proper ways to resolve the problems coming from EMR.