• Title/Summary/Keyword: clinical document form

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Generation, Storing and Management System for Electronic Discharge Summaries Using HL7 Clinical Document Architecture (HL7 표준임상문서구조를 사용한 전자퇴원요약의 생성, 저장, 관리 시스템)

  • Kim, Hwa-Sun;Kim, Il-Kon;Cho, Hune
    • Journal of KIISE:Databases
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    • v.33 no.2
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    • pp.239-249
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    • 2006
  • Interoperability has been deemphasized from the hospital information system in general, because it is operated independently of other hospital information systems. This study proposes a future-oriented hospital information system through the design and actualization of the HL7 clinical document architecture. A clinical document is generated using the hospital information system by analysis and designing the clinical document architecture, after we defined the item regulations and the templates for the release form and radiation interpretation form. The schema is analyzed based on the HL7 reference information model, and HL7 interface engine ver.2.4 was used as the transmission protocol. This study has the following significance. First, an expansion and redefining process conducted, founded on the HL7 clinical document architecture and reference information model, to apply international standards to Korean contexts. Second, we propose a next-generation web based hospital information system that is based on the clinical document architecture. In conclusion, the study of the clinical document architecture will include an electronic health record (EHR) and a clinical data repository (CDR), and also make possible medical information-sharing among various healthcare institutions.

A Development Study of Common Clinical Document Forms for Traditional Korean Medicine Information Standardization (한의 정보 표준화를 위한 공통 임상 기록 서식 개발 연구)

  • Moon, Jin-Seok;Kim, Jeong-Cheol;Park, Sae-Wook;Ko, Ho-Yeon;Kim, Bo-Young;Kang, Byoung-Gap;Kang, Kyung-Won;Choi, Sun-Mi
    • The Journal of Korean Medicine
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    • v.30 no.1
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    • pp.40-50
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    • 2009
  • Objectives: The clinical document forms, a format for collecting clinical data, is the most fundamental object of standardization. Doctors must have a mutual understanding of the clinical chart. Methods: Clinical document forms were developed by investigating existing conditions in hospitals and conducting demand surveys, doing literature research, and seeking expert advice for the improvement of version 1.0. In addition, an organization of a network of 19 Oriental medical doctors and nurses, 190 patients, and users of collected and assessed data was formed to come up with version 2.0. Results: The overall format was divided into different portions that the patient, nurse, and doctor must fill out, respectively. The patient's section consists of demographic data, lifestyle details, history, and symptoms. The data to be supplied by the nurse include the patient's vital signs and anthropometric parameters. As for the doctors, they are to supply data regarding the patient's palpitation, the detailed symptoms of the patient's head, ophthalmological and otorhinolaryngological symptoms (mouth), respiration, circulatory organ and chest conditions, digestive-organ conditions (thirst), neuropsychiatric conditions, reproductive system, musculoskeletal system, skin (depilation), etc. Conclusions: Common clinical chart development is the prior question to Traditional Korean Medicine standardization. A web-based clinical document format should be developed to support diagnosis and treatment, and furthermore EMR (electronic medical record system) and EHR (electronic health record) developed. Clinical information could be shared through a network of medical institutions and be useful Traditional Korean Medicine for evidence-based medicine.

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Design of a Hospice Referral System for Terminally Ill Cancer Patients Using a Standards-Based Health Information Exchange System

  • Lim, Kahyun;Kim, Jeong-Whun;Yoo, Sooyoung;Heo, Eunyoung;Ji, Hyerim;Kang, Beodeul
    • Healthcare Informatics Research
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    • v.24 no.4
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    • pp.317-326
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    • 2018
  • Objectives: The demand for hospice has been increasing among patients with cancer. This study examined the current hospice referral scenario for terminally ill cancer patients and created a data form to collect hospice information and a modified health information exchange (HIE) form for a more efficient referral system for terminally ill cancer patients. Methods: Surveys were conducted asking detailed information such as medical instruments and patient admission policies of hospices, and interviews were held to examine the current referral flow and any additional requirements. A task force team was organized to analyze the results of the interviews and surveys. Results: Six hospices completed the survey, and 3 physicians, 2 nurses, and 2 hospital staff from a tertiary hospital were interviewed. Seven categories were defined as essential for establishing hospice data. Ten categories and 40 data items were newly suggested for the existing HIE document form. An implementation guide for the Consolidated Clinical Document Architecture developed by Health Level 7 (HL7 CCDA) was also proposed. It is an international standard for interoperability that provides a framework for the exchange, integration, sharing, and retrieval of electronic health information. Based on these changes, a hospice referral scenario for terminally ill cancer patients was designed. Conclusions: Our findings show potential improvements that can be made to the current hospice referral system for terminally ill cancer patients. To make the referral system useful in practice, governmental efforts and investments are needed.

Clinical Information Interchange System using HL7-CDA

  • Jung, Yong Gyu;Lee, Young Ho
    • International journal of advanced smart convergence
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    • v.1 no.2
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    • pp.47-51
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    • 2012
  • In highly developed society, information and communication technologies are widely used for better medical services. These information and communication technologies should be more and more acceptable in all hospitals for exchange medical records. EMR becomes more convenient than the previously used paper charts. It will be able to record medical institutions every time and dual treatment. Each is different specifications for each medical institution to use the program or document to exchange it. The personal clinic records still does not exchange well. To solve this gap between medical alienation, this paper describes the concepts of HL7-CDA and proposes types of telemedicine system. To resolve time and space constraints, new form of treatment methods presents in future directions after described about related systems. CDA enables electronic medical records to the each medical center and gradually expanded by exchanging the patient's medical records. This paper is using XML-based CDA documents as a hierarchical for medical information exchange standards compliant HL7-CDA documents. It could be possible currently used structural variety of multimedia data. Thus It is able to send and receive HL7-CDA-based medical information and clinical information to identify the medical institutions of medical information with interchange system design and building standards, and through mutual exchange of clinical information.

Autoimmune encephalitis and epilepsy: evolving definition and clinical spectrum

  • Seo, Joo Hee;Lee, Yun-Jin;Lee, Ki Hyeong;Gireesh, Elakkat;Skinner, Holly;Westerveld, Michael
    • Clinical and Experimental Pediatrics
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    • v.63 no.8
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    • pp.291-300
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    • 2020
  • Advances in autoimmune encephalitis studies in the past 10 years have led to the identification of new syndromes and biomarkers that have transformed the diagnostic approach to the disorder. The disorder or syndrome has been linked to a wide variety of pathologic processes associated with the neuron-specific autoantibodies targeting intracellular and plasma membrane antigens. However, current criteria for autoimmune encephalitis are quite dependent on antibody testing and responses to immunotherapy, which might delay the diagnosis. This form of encephalitis can involve the multifaceted presentation of seizures and unexpected behavioral changes. The spectrum of neuropsychiatric symptoms in children is less definitive than that in adults, and the incorporation of clinical, immunological, electrophysiological, and neuroradiological results is critical to the diagnostic approach. In this review, we document the clinical and immunologic characteristics of autoimmune encephalitis known to date, with the goal of helping clinicians in differential diagnosis and to provide prompt and effective treatment.

Distribution of Symptoms and Syndrome Differentiation Using Common Clinical Document Forms - Focused on Deficiency Syndrome Differentiation - (한의 공통 임상 기록 서식을 이용한 변증(辨證)과 증상(症狀)의 분포 조사 - 허증(虛證)을 중심으로 -)

  • Moon, Jin-Seok;Kim, Jeong-Cheol;Kang, Byoung-Gab;Kim, Bo-Young;Kang, Kyung-Won;Choi, Sun-Mi
    • Korean Journal of Oriental Medicine
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    • v.14 no.2
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    • pp.47-66
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    • 2008
  • Background: It is insufficient information that are syndrome differentiations and detail symptoms in Korean. Methods: 19 traditional korean medical agencies collected 190 cases with vital sign, body measurement, patient own symptoms report and doctor diagnosis. And then we analyzed general distributions and comparisons of deficiency and non-deficiency. Results: The most past histories, in order, were the arthritis(20%), gastroenteropathy, hypertension, anemia, diabete mellitus. In chief complains, musculoskeletal occupies 60 percent of the total, and digestive system, head in order. In the syndrome differentiation, it appeared deficiency, spleen, Qi deficiency in order. Age(p=0.000), systolic blood pressure(p=0.044) and the waist-hip ratio(p=0.000) was significantly higher in the deficiency group compared with non-deficiency group. Patients with condition which dislikes the wind and with anxiety and with amazing and fear(驚恐) were significantly more in deficiency group(p=0.029, p=0.017, p=0.044). Conclusions: These statistics are continually revised report and it will be reported comparison of several syndrome differentiations and therapeutic effects by treatment methods.

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Development of CRF and SOPs for the Identification of Risk Factors of the Cerebrovascular Diseases in the East and West Medicine (뇌혈관질환의 한양방적인 위험요인 규명 및 진단 표준화 연구를 위한 CRF 및 SOP 개발)

  • Ko Seong-Gyu;Jun Chan-Yong;Park Jong-Hyeong;Han Chang-Ho;Ko Ho-Yeon;Yoon Yoo-Sik;Choi Seon-Mi;Kim Jung-Gil;Jung Woo-Sang;Moon Sang-Kwan;Kim Yeung-Suk;Bae Hyung-Sup;Cho Ki-Ho
    • The Journal of Korean Medicine
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    • v.27 no.1 s.65
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    • pp.204-219
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    • 2006
  • Objectives : This study is to report the proceeding of the project sponsored by the ministry of science and technology of Korea for the stroke study titled as 'fundamental study for standardization and objectification of differentiation and pattern identification of symptoms of Oriental Medicine in stroke'. Methods and Results : We works for clinical research and molecular epidemiology center and we are in charge of the development of case report form, education of the investigators, data entry, data validation, and analysis. In the process of this project, we need to development of standard operating procedures for development and education for the case report form. Conclusions : This study is to let researchers for Traditional Korean Medicine and clinical research know how to develop of case report form and standard operating procedures in clinical researches and maintain the resource document and data.

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Current Status of Management on Pharmacopuncture in Korea through Introduction of an Accreditation System

  • Sung, Soo-Hyun;Shin, Byung-Cheul;Park, Min-Jung;Kim, Kyeong Han;Kim, Ji-Won;Ryu, Ji-Yeon;Park, Jang-Kyung
    • Journal of Pharmacopuncture
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    • v.22 no.2
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    • pp.75-82
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    • 2019
  • Objectives: Pharmacopuncture is a new form of acupuncture treatment that injects herbal medicine into acupuncture points. This paper introduces the management status of pharmacopuncture through accreditation, and examines the effect of accreditation on pharmacopuncture management. Methods: The Accreditation System of External Herbal Dispensaries (EHDs) of traditional Korean medicine clinics announced by the Ministry of Health and Welfare in September 2018 were investigated. Results: The Accreditation System of EHDs assesses and certifies herbal medicine and pharmacopuncture preparations. Regular components for the 'pharmacopuncture' certification consist of nine standards, 30 categories, and 165 items. The nine standards include: herbal dispensary facilities, clean room management, management and organization operation, employee management, document management, continuous quality control, herbal medicine management, management of preparation, and pavement management. Conclusion: Through EHD accreditation and certification system, traditional Korean medicine clinics and EHDs can now manage pharmacopuncture medicine quality and promise safe pharmacopuncture treatment for the people.

A Scientometric Analysis of 20 Years of Research on Breast Reconstruction Surgery: A Guide for Research Design and Journal Selection

  • Moghimi, Mehrdad;Fathi, Mehdi;Marashi, Ali;Kamani, Freshteh;Habibi, Gholamreza;Hirbod-Mobarakeh, Armin;Ghaemi, Marjan;Hosseinian-Sarajehlou, Mahdi
    • Archives of Plastic Surgery
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    • v.40 no.2
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    • pp.109-115
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    • 2013
  • Background Breast reconstruction refers to the rebuilding of a woman's breast using autologous tissue or prosthetic material to form a natural-looking breast. It is increasingly offered to women undergoing mastectomy for breast cancer. However, there is no systematic analysis available for the expanding area of research on breast reconstruction. Methods A bibliometric method was used to obtain a view of the scientific production about breast reconstruction by data extracted from the Institute for Scientific Information (ISI). Specific parameters were retrieved from the ISI. Articles about breast reconstruction were analyzed to obtain a view of the topic's structure, history, and document relationships using HistCite software. Trends in the most influential publications and authors were analyzed. Results The number of articles was constantly increasing. Most highly cited articles described the methods of flap construction in the surgery. Other highly cited articles discussed the psychological or emotional aspects of breast reconstruction, skin sparing mastectomy, and breast reconstruction in the irradiated breast. Conclusions This was the first breast reconstruction scientometric analysis, representing the characteristics of papers and the trends of scientific production. A constant increase in the number of breast reconstruction papers and also the increasing number of citations shows that there is an increasing interest in this area of medical science. It seems that most of the research in this field is focused on the technical aspects of surgery.

The comparative study on the psychotherapy of oriental and occidental medicine (정신요법(精神療法)에 대(對)한 동서의학적(東西醫學的) 고찰(考察))

  • Ha, Su Young;Lee, Sang Ryong
    • Journal of Haehwa Medicine
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    • v.8 no.2
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    • pp.341-359
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    • 2000
  • The following result are obtained through that comparative study on the psychotherapy of oriental and occidental medicine. 1. The shamanism(祝由) and active emotion therapy(移精變氣療法) are a primitive form of psychotherapy. It is an opinion that between active emotion therapy(移精變氣療法) and psychoanalytic therapy or supportive psychotherapy are similar. Also, the basic cognition pattern of shamanism(祝由) is projection. 2. Taoism is inseparably related to the psychotherapy of korean oriental medicine, the major thought has become the ideal base of oriental psychotherapy. 3. According to study of clinical document in relation to oriental psychotherapy, psychotherapy had been widely used by medical cure. 4. The five emotion restraint therapy is a high level psychotherapy of oriental medicine. Oriental psychotherapy that disease caused by surprising must be cure by surprising is like to systematic desensitization in western, and that pseudopsychosis must be cure by patient rely on doctor is like to suggestive therapy in western. 5. There are psychotherapy in western that Supportive psychotherapy, Short-term dynamic psychotherapy, Psychoanalytic therapy, Group psychotherapy, Family therapy, Morita therapy, Hypnotherapy, Autogenic training, Behavioral therapy, Milieu therapy, Occupational therapy, Psychodrama, the others. I think that they have wide application to the psychotherapy of korean oriental medicine.

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