• Journal of Hospice and Palliative Care
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• 제11권1호
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• pp.12-29
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• 2008

목적: 본 연구는 의사, 간호사, 사회복지사, 사목자, 자원봉사자로 구성된 호스피스팀원들이 각자의 전문영역에서 중복되지 않으면서 필요한 정보를 효과적으로 공유할 수 있는 표준화된 기록지를 개발하여 호스피스 대상자들에게 적절한 돌봄을 제공하는데 도움을 주고자 수행되었다. 방법: 초기 개발된 기록지를 근거로 문헌 고찰과 전문가 집단의 자문을 통해 수정 보완하는 델파이 기법을 이용한 방법론적 연구이다. 결과: 각 전문가별로 총 27명의 자문가의 의견을 수렴하여 최종 11가지 가정 호스피스 팀 기록지가 개발되었다: 등록기록지, 초기 평가기록지 (의사용), 경과기록지(의사용), 방문 기록지 (간호사용, 봉사자용), 영적돌봄 초기 면담지, 방문 기록지 (사목자용),사회적 돌봄 면담지 (사회복지사용), 사별가족 초기 면담지, 사별가족 돌봄 기록지, 종결 기록지. 결론: 본 연구를 통해 개발된 11종의 호스피스 팀 기록지는 가정호스피스 팀원간의 의사소통을 원활히 하고 질 높은 서비스를 제공하는데 기여할 수 있으리라고 기대된다.

• 한국의료질향상학회지
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• 제9권2호
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• pp.176-197
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• 2002

Backgound : This study is to suggest the standardized format of the clinical sheets and the standardized items of every clinical sheet. The standardization of the medical records will increase the faithfullnes of the contents in them and it will contribute to construct the good health information system. Method : From Jan. 1st. 2001 to March 31st 2001, we gathered as many paper clinical sheets as possible by every class of institutions to review the faithfulness of the clinical contents in them. Clinical sheets of 9 tertiary care hospitals, 6 general hospitals and 56 clinics were gathered. Two experienced medical record administrators reviewed them. The review focus was to check whether the items recommend by the hospital standardization review criteria and hospital service evaluation organization were appeared in the clinical sheets and whether the contents of every item were written. Results : Tertiary care hospitals; In case of administrative data, the contents were filled well if the items were fixed. The clinical data like C.C, history,physical examiniation were filled well, but if the items were not fixed, some items were omitted. The result is that more items are to be filled if they are fixed. General hospitals Administrative data were filled more than 50%. Final diagnosis was filled about 66.7%.But other clinical data were not filled well and not many clinical related items were appeared in the sheets.In the legal point of view, the reason for visiting hosptals or the right diagnosis, patient condition at discharge could not be confirmed well.In surgery cases, surgical procedures could not be confirmed well as many surgical related information(surgery time, fluids and blood, number of sponges, biopsy, etc) were omitted. Clinics More than 70% administrative data were filled and fixed as items. Among the clinical related data, laboratory result was the most credible data. But without the right diagnosis, drug orders were given and doctors' written signatures were not appeared over 96.4%. So the clinical sheets cannot be used as a legal document. Conculusion : There was a tendency that the contents were filled well if the items were fixed in the documents, We also suggest a clinical check list to review the completeness and faithfulness of the clinical sheets. If many hospitals use the suggested clincal check list and if they make the necessary items fixed in the clinical sheets, the quality of the medical record will increase dramatically.

• Journal of Nutrition and Health
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• 제37권8호
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• pp.688-700
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• 2004

This study was conducted to analyze how appropriate the on-line nutrition information was externally as a web information. Four-hundred-ninety-seven web sites from 5 internet search engines (Yahoo, Empas, Nate, Hanmir, Naver) were selected on the basis of April 25th, 2004. The skillful personnels monitored them about 8 evaluating categories: clarity, purpose, authority, durability, advertisement, privacy and/or security, responsibility, and contents. Forty percent of the selected web sites were operated by the companies which had commercial purpose like internet shopping malls and 5.6% by academies, societies, research institutions, schools/colleges and public institutions. Most of web sites (76.1 %) were managed for advertisements and sales of companies' commodities, and 32.6% had the food and nutrition information as first purpose. Ninety-three percent of web sites were targeted to healthy individuals through whole life cycle. Specifically, there were lots of web sites for the obesity which were offered by diet related companies. Of the 497 web sites, 193 mentioned the name providing the nutrition information, but only 1/3 had reliability on their specialty. As a source of nutrition information, 52.7% of web sites were using 'books of the major field' and 42.0% 'newspapers' and 23.7% 'broadcasting', respectively. Most web sites mentioned 'setting-up date' but not 'renewal date'. Thirty-six percent of web sites took '2 - 3 days' for the operators to answer the questions through the bulletin. Forty-seven percent of web sites answered' 1 - 10 questions' per 1 week, but 40.1 % of them didn't answer for a week at all. There were 118 web sites (23.7%) to record the connected frequencies and 36.0% of them put the advertisements. Around 96% of web sites mentioned feedback addresses. Among the menus of web sites, 68.0% were about self-advertisement and 64.0% about nutrition information. Each web site was scored to judge its external quality according to the operators by selecting 13 items. Web sites managed by public institution had highest scores (9.5), and lowest in private vendors', food companies' and individual web pages. Among search engines, Naver got the highest score of 7.0 and Nate the lowest one of 6.1. As it was only the pilot study, there were several limits in evaluating tools, time and monitored quantity. To make monitoring of on-line nutrition informatiions actively, standardized monitoring forms might be developed under the integrated studies.