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http://dx.doi.org/10.3743/KOSIM.2012.29.3.257

A Study on the Current Status and Tasks of Medical Records Management: Focused on Applying the KS X ISO 15489 to the Y Hospital  

Lee, Eun-Mi (이화여자대학교 대학원 보건관리학과)
Kim, Myeong (이화여자대학교 건강과학대학 보건관리학과)
Hee, Jin (명지대학교 기록정보과학전문대학원)
Publication Information
Journal of the Korean Society for information Management / v.29, no.3, 2012 , pp. 257-285 More about this Journal
Abstract
As the electronic medical records systems (EMRs) are introduced into the hospitals in Korea and the needs of chief stakehoders of medical records are changed, the environments related to creating and managing medical records has been changed dynamically. At this moment it might be meaningful to examine medical records based on records management principles rather than information management principles. The purpose of this paper is to apply the KS X ISO 1549 standards, which covers the principles of records management, to hospital medical records management and assess the current quality of medical records management, and define a few tasks of improvement for hospitals. To achieve this goal, this study has performed following activities: Firstly, principles that could be applied to medical records management were prepared for each record management steps described in the standards, such as capture, registration, classification, storage, access, trace and disposition, and 22 principles were selected from those 7 steps of the record management. Secondly, the Y hospital, which is affiliated with a medical school in Seoul, was chosen to evaluate the current situation regarding medical records management. The department head of the medical records management team in Y hospital was interviewed and the present status was evaluated according to each principle. Thirdly, tasks for improvement were suggested, in such stages as access, trace and disposition. With this study as a cornerstone, useful implications are expected to be gathered from future studies that apply standards for metadata of records, management systems for records, and record management systems to medical record management in hospitals.
Keywords
medical records; EMR(electronic medical records); records management assessment; health information manager(HIM); KS X ISO 15489;
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