Clinical Endoscopy

  • 제41권4호
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  • Pages.189-195
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  • 2010
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  • 2234-2400(pISSN)
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  • 2234-2443(eISSN)
대한소화기내시경학회 (The Korean Society of Gastrointestinal Endoscopy)
권호 표지

전자내시경의무기록을 위한 내시경 보고서

The Endoscopic Report for Endoscopic Electronic Medical Records

  • 조유경 (가톨릭대학교 의과대학 서울성모병원 소화기내과학교실)
  • Cho, Yu-Kyung (Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine)
  • 투고 : 2010.07.31
  • 심사 : 2010.09.30
  • 발행 : 2010.10.30
⟨ 이전 논문 다음 논문 ⟩

초록

내시경 분야에서 전자내시경의무기록 시스템은 간단한 내시경 결과보고서의 작성을 넘어 포괄적인 내시경실 관리시스템으로 발전하고 있다. 전자내시경의무기록 시스템은 내시경의사의 효율뿐 아니라 내시경실 관리의 효율을 높일 수 있다. 전산화된 내시경기록은 임상연구와 질 관리가 가능하도록 내시경결과의 데이터베이스 생성을 가능하게 한다. 그러기 위해서는 내시경 보고서의 구조를 계획할 때부터 표준 보고서의 형식을 표준화된 용어를 선택하여 결과를 입력하는 것이 중요하다. 이미 최소표준용어가 내시경의 전산기록을 위해 개발되어 사용되고 있다. 권장 내시경보고서의 사용과 양질의 영상기록은 내시경 질 관리 면에서도 중요하다.

Electronic medical record systems for endoscopic data have evolved from simple endoscopy report generators to endoscopy unit managers. These systems may improve patient care and enhance endoscopy unit efficiency and productivity. Regarding endoscopists, the introduction of automated endoscopic reporting using endoscopic electronic medical records should permit database establishment. The systematic development of the structure and content of endoscopic reports is mandatory before it is possible to create large, clinically useful databases of endoscopic reports. An accurate endoscopic report is based on the use of standard terminology, a standard classification method, and image and video recordings. The minimal standard terminology was developed as a minimum list of terms that could be included in a computer system for endoscopic reporting. A standard framework of endoscopic reports using standard terminology and a minimal checklist of endoscopic images are also needed for quality assurance.

키워드

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