• Title/Summary/Keyword: the clinical document

Search Result 126, Processing Time 0.023 seconds

Design and Implementation of a Nursing Records for the Nursing Process for Use Within the Health Level 7 Clinical Document Architecture (HL7 임상문서구조의 기반 한 간호과정을 위한 간호기록지의 설계 및 구현)

  • Kim, Hwa-Sun;Tran, Tung;Kim, Hyung-Hoi;Lee, Eun-Joo;Cho, Hune
    • Journal of Korea Multimedia Society
    • /
    • v.9 no.8
    • /
    • pp.1054-1066
    • /
    • 2006
  • This study proposes a new paradigm hospital information system through the nursing classification system and design of the HL7 clinical document architecture (Health Level Seven CDA) for information-sharing among various healthcare institutions. Nursing information CDA are included coding systems of nursing diagnosis, nursing intervention, nursing activity and outcomes. And, we have developed CDA generator for active generation of XML document. This study aims to facilitate the optimum care by providing health information required for individuals to nursing specialists in real-time, to help improvements in health, to improve the quality of productive life. 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 healthcare information-sharing among various healthcare institutions.

  • PDF

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
    • /
    • v.33 no.2
    • /
    • pp.239-249
    • /
    • 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
    • /
    • v.30 no.1
    • /
    • pp.40-50
    • /
    • 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.

  • PDF

Design and Implementation of Electronic Medical Record System Based on HL7-CDA for the Exchange of Clinical Information (임상 정보교환을 위한 HL7-CDA 기반의 전자의무기록 시스템의 설계 및 구현)

  • Cho, Ik-Sung;Kwon, Hyeog-Soong
    • The Journal of Korean Institute of Communications and Information Sciences
    • /
    • v.33 no.5B
    • /
    • pp.379-385
    • /
    • 2008
  • For the sharing and exchange of information between medical clinics, the clinical document has to be built on a standardized protocol such as a HL7-CDA. But it is difficult to exchange information between medical clinics because clinical document such as electronic medical record that include text and image, have different structure of document and type of expression. In this paper, we propose the electronic medical record system based on HL7-CDA that can share and exchange clinical information between medical institute. For this purpose, we have to design the schema of the clinical document architecture after we select the essential items of medical record and define templates. The proposed system can minimize integrating process and save parsing time when clinical information exchange and refer, by converting electronic medical record to base64 encoding scheme and integrate it in a XML document.

A study of psychotherapy by means of oriental medicine though the Giungoroen(至言高論)-Focusing on Ancient clinical document (지언고론(至言高論)에 의한 한의학적(韓醫學的) 정신치료(精神治療)에 대(對)한 연구(硏究) (의안(醫案)을 중심으로))

  • Gu Byong-Su;Kim Geun-Woo
    • Journal of Oriental Neuropsychiatry
    • /
    • v.12 no.1
    • /
    • pp.29-45
    • /
    • 2001
  • Objectives: In order to overcome psychotherapeutic problems though the theory of oriental medicine by means of the Giungoroen(至言高論-wise saying and lofty opinion). Methods: This research was done by comparing the contents of psychotherapeutic ancient clinical document with the western medical method of psychotherapy Results: 1. Inquire into the clinical document, the psychotherapy is used treatment of wide area disease inclusive of neuropsychiatric disease different from the western medicine. 2. Inquire into the method of psychotherapy, the supportive psychotherapy and behavior therapy is applied. 3. In case of psychotherapy and treatment of medicines is done at the same time, treatment of medicines followed psychotherapy. 4. A viewpoint of Yusic(唯識-vijnaptim-atra)-a field of Buddhism, possibility of psychotherapy is showed. 5. A doctor's oriental thought and oriental medical Preservation of Health view was based. 6. The change of patient's the emotion and will is focused than disease itself. Conclusion: When western medical method of psychotherapy is complemented by a oriental thought and oriental medical Preservation of Health view, the good effects is hoped in psychotherapy.

  • PDF

A Study of clinical document in relation to Neuropsychiatric disease(Focusing of Ancient Chinese (Song<宋>, Keum<金>, Won<元>, Myung<明> clinical document) (신경정신과(神經精神科) 질환(疾患)과 관련(關聯)된 의안(醫案)의 연구(硏究) (중국(中國) 송(宋)$\cdot$금(金)$\cdot$원(元)$\cdot$명(明) 시대(時代) 의안(醫案)을 중심(中心)으로))

  • Kwon Bo-Hyung;Ku Byung-Su
    • Journal of Oriental Neuropsychiatry
    • /
    • v.8 no.1
    • /
    • pp.215-235
    • /
    • 1997
  • according to study of clinical document in relation to Neuropsychiatric disease in Ancient Chinese(Song, Keum, Won, Myung) clinical document the result were obtained as follows. 1. A main point is Jeul-Jin<切診> in diagnosis, that is Hyun-Maeg<弦脈> is liver disease, Whual Mag<滑脈> is gallbladder disease, Sag Mag<數脈> is fever.2. Doctors in Song<宋>, Keum<金>,Won<元> enumerationed many diseases are cause by emotion.3. Oriental psychotherapy that Diseases caused by surprising must be cure by surprising is like to systematic desensitization in Westem.4. Oriental psychotherapy that pseudopsychosis must be cure by patient rely on doctor is like to suggestive therapy in western.5. It is similar to suggestive therapy in western medicine that Sadness ,anguish and frustration induce disease.6. Headache is caused by fever, energy deficience and angry.7. Imsomnia is not caused by hsart disease, but gallbladder or liver.8. Schizophrenia is caused by shocking and a sort of fever.9. Epilepsy is caused by a sort of fever, shocking and fetal disease.10 Schizophrenia(in case of manic state) is caused by fever and shocking, and imaginary pregnancy is considered as schizophrenia.

  • PDF

Health Level 7 Version 3 based Generating Clinical Document Architecture for Medication Administration System (HL7 버전 3 기반의 투약관리시스템을 위한 임상문서구조의 생성)

  • Kim, Genun-Hee;Cho, Su-Mi;Lee, Eun-Joo;Kim, Hwa-Sun;Cho, Hune
    • Journal of Korea Multimedia Society
    • /
    • v.11 no.3
    • /
    • pp.386-397
    • /
    • 2008
  • This study proposes the actualization of a standard data model for activities through the development of clinical document architecture for medication administration using the health level 7 development frameworks(HDF) process based on object oriented analysis and development method of health level 7 V 3. Medication administration is the most common activity performed by clinical professionals at healthcare settings. A standardized information model and structured hospital information system are necessary to achieve evidence-based clinical activities. We had used HDF and various tools(Rose tree, RMIM designer, V3 generator) to create the clinical document architecture(CDA). This allowed us to illustrate each step of the HDF in the administration of medication. This study generated a information model of the medication administration process, which is one clinical activity. It should become a fundamental conceptual model for understanding international standard methodology by information technology(IT) developers with the objective of modeling healthcare information systems.

  • PDF

A New Method of Registering the XML-based Clinical Document Architecture Supporting Pseudonymization in Clinical Document Registry Framework (익명화 방법을 적용한 임상진료문서 등록 기법 연구)

  • Kim, Il-Kwang;Lee, Jae-Young;Kim, Il-Kon;Kwak, Yun-Sik
    • Journal of KIISE:Software and Applications
    • /
    • v.34 no.10
    • /
    • pp.918-928
    • /
    • 2007
  • The goal of this paper is to propose a new way to register CDA documents in CDR (Clinical Document Repository) that is proposed by the author earlier. One of the methods is to use a manifest archiving for seamless references and visualization of CDA related files. Another method is to enhance the CDA security level for supporting pseudonymization of CDA. The former is a useful method to support the bundled registration of CDA related files as a set. And it also can provide a seamless presentation view to end-users, once downloaded, without each HTTP connection. The latter is a new method of CDA registration which can supports a do-identification of a patient. Usually, CDA header can be used for containing patient identification information, and CDA body can be used for diagnosis or treatment data. So, if we detach each other, we can get good advantages for privacy protection. Because even if someone succeeded to get separated CDA body, he/she never knows whose clinical data that is. The other way, even if someone succeeded to get separated CDA header; he/she doesn't know what kind of treatment has been done. This is the way to achieve protecting privacy by disconnecting association of relative information and reducing possibility of leaking private information. In order to achieve this goal, the method we propose is to separate CDA into two parts and to store them in different repositories.

Design of EMR Sharing System based on HL7 Message over Web Environment (웹 환경에서 HL7 메시지 기반 전자의무기록 공유 시스템 설계)

  • Yoo JaeMyeong;Lee SungChul;Kim IlKon;Cho Hune;Bum HeeSeung;Lee GueeSang
    • Proceedings of the IEEK Conference
    • /
    • 2004.06a
    • /
    • pp.285-288
    • /
    • 2004
  • This paper has been studied a EMR Sharing System using HL7 Message and CDA Document. HL7 Message is a Transaction for clinical data sharing between hospital-based. The CDA for document exchange supports shared care between hospital-based and community-based physicians, knowledge integration by permitting external links to other documents, and outcomes research through the capture of discrete and coded clinical data. And then this paper has designed XML based CDA for document exchange and interactive Hospital-based Transaction based on HL7 Message.

  • PDF

Introduction of Clinical and Laboratory Standards Institute Antibiotic Susceptibility Testing Subcommittee Meeting (Clinical and Laboratory Standards Institute의 항생제 감수성 검사 소위원회 회의 소개)

  • Chang, Chulhun L.
    • Annals of Clinical Microbiology
    • /
    • v.21 no.4
    • /
    • pp.69-74
    • /
    • 2018
  • Laboratory medicine is a specialized division that supports physicians in the care of patients by providing rapid and accurate in vitro diagnostic tests. Standardization of every component of a specific test is essential for producing accurate results. The Clinical and Laboratory Standards Institute (CLSI) was founded to develop a formal consensus process for standardization in 1968, and has been publishing standards and guidelines covering all aspects of clinical, research, and other laboratory work. CLSI guidelines are widely used around the world for standardization. The CLSI antimicrobial susceptibility testing subcommittee (AST SC) consists of 6 standing and many ad hoc working groups. Members of the AST SC review submitted proposals and suggestions, decide on approving these submissions in face-to-face meetings held twice a year, and revise CLSI documents accordingly. As these face-to-face meetings are open to anyone who registers to attend, I strongly encourage the members of our Society to attend and actively participate in document development.