• 제목/요약/키워드: Clinical Records

검색결과 2,228건 처리시간 0.025초

Clinical Information Interchange System using HL7-CDA

  • Jung, Yong Gyu;Lee, Young Ho
    • International journal of advanced smart convergence
    • /
    • 제1권2호
    • /
    • pp.47-51
    • /
    • 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.

조선 인목왕후의 진료 기록 연구 - 『조선왕조실록』과 『승정원일기』를 중심으로 - (A Study on Clinical Records of Queen Inmok)

  • 김민선;하동림;김남일
    • 한국의사학회지
    • /
    • 제32권2호
    • /
    • pp.91-104
    • /
    • 2019
  • In this paper, the clinical records of Queen Inmok has been studied and the impact of historical events on her life has been analyzed. This paper has extracted her medical records during King Seonjo's and King Injo's period from the Annals and the Daily Records of Royal Secretariat of Joseon Dynasty, and then contemplated their medical implications consulting Donguibogam as a primary reference. Queen Inmok had been yang deficiency after national mourning. But suffering a series of misfortunes, she was ill with fire-heat (火熱) syndrome and finally passed away suffering from high fever, frequent diarrhea and profuse sweating. At that time, practitioners abused cold therapy following Jin Yuan Sia Jia (金元四大家), so they missed Queen Inmok's yang deficiency.

'계획에 없던 재수술' 의 분석 (An analysis of unplanned reoperation)

  • 김은경;조성현;김창엽;오병희
    • 한국의료질향상학회지
    • /
    • 제2권1호
    • /
    • pp.118-124
    • /
    • 1995
  • Background: Clinical indicators are objective measures of process or outcome of patient care in quantitative terms. This study aims to review the medical records of patients who 'return to operating room during the same admission', which is one of the critical clinical outcomes, and describe the result by unplanned reoperation rate. Methods: Computerized patient registry was used for selecting subject conditions. For medical records retrieved, two nurse evaluators identified the presence of explicit reoperation planning in medical records. Results: Overall reoperation rate was 2.8% and unplanned reoperation rate 1.3%. The main category of reoperation cause was the postoperative bleeding. Duration of stay from previous operation to reoperation of the unplanned group, 12.7 days, was shorter than that of the planned(p< .05). The differences did not reach statistical significance in age, sex and length of stay. Conclusion: Results suggested that unplanned reoperation rate was lower than 'threshold' level other institutions had established. However, this result could become comparable only after management of medical records would be improved and risk adjusted.

  • PDF

간호대학생의 간호기록 작성 지식의 중요도, 비판적 사고성향, 핵심간호술에 대한 수행 자신감이 임상수행능력에 미치는 영향 (Effects of Importance in the Knowledge of Nursing Records, Critical Thinking Disposition and Self-confidence of Core Nursing Skills on Clinical Competence with Nursing Students)

  • 오은영
    • 디지털융복합연구
    • /
    • 제19권12호
    • /
    • pp.627-639
    • /
    • 2021
  • 본 연구의 목적은 간호대학생의 간호기록 작성 지식의 중요도, 비판적 사고성향, 핵심간호술에 대한 수행 자신감이 임상수행능력에 영향을 미치는 요인을 확인하기 위함이다. 간호대학생 201명을 대상으로 2020년 10월부터 12월까지 자가보고식 설문조사를 수행하였다. 수집된 자료는 SPSS WIN 20을 이용하여 다중회귀분석방법으로 분석하였다. 연구결과 간호대학생의 임상수행능력에 영향을 미치는 요인은 비판적 사고성향, 간호기록 작성 지식의 중요도, 핵심간호술에 대한 수행 자신감(β=.43, .31, .24)순이었고, 설명력은 61.9%이었다. 따라서 간호대학생의 임상수행능력 향상을 위해 본 연구에서 확인된 주요요인들을 통합적으로 활용할 수 있는 교수학습전략을 개발하고 적용해볼 것을 제안한다.

만성 바이러스성 B형 간염 환자에서 HBeAg이 혈청전환된 1례 (A Case Report of HBeAg Seroconversion in Chronic Viral Hepatitis B)

  • 최은솔;김하연;배정한;장은경;김영철;이장훈
    • 대한한방내과학회지
    • /
    • 제37권3호
    • /
    • pp.529-538
    • /
    • 2016
  • Objectives: The purpose of this case study is to report the efficacy and safety of treatment with Korean medicine of a patient with HBeAg-positive chronic viral hepatitis B.Methods: The patient took Korean medicine (mainly Injinchunggan-tang-gamibang) from July 20th, 2010, to March 14th, 2016, without any antiviral or interferon therapy. Changes to laboratory records, abdomen ultrasonography, and clinical symptoms were reviewed.Results: The laboratory records showed that AST, ALT, and HBV DNA had decreased to normal ranges, and HBeAg showed seroconversion. Clinical symptoms also improved after taking Korean medicine.Conclusion: The results suggest that treatment with Korean medicine and without antiviral or interferon therapy could be effective for HBeAg-positive chronic hepatitis B.

Perspectives on Clinical Informatics: Integrating Large-Scale Clinical, Genomic, and Health Information for Clinical Care

  • Choi, In Young;Kim, Tae-Min;Kim, Myung Shin;Mun, Seong K.;Chung, Yeun-Jun
    • Genomics & Informatics
    • /
    • 제11권4호
    • /
    • pp.186-190
    • /
    • 2013
  • The advances in electronic medical records (EMRs) and bioinformatics (BI) represent two significant trends in healthcare. The widespread adoption of EMR systems and the completion of the Human Genome Project developed the technologies for data acquisition, analysis, and visualization in two different domains. The massive amount of data from both clinical and biology domains is expected to provide personalized, preventive, and predictive healthcare services in the near future. The integrated use of EMR and BI data needs to consider four key informatics areas: data modeling, analytics, standardization, and privacy. Bioclinical data warehouses integrating heterogeneous patient-related clinical or omics data should be considered. The representative standardization effort by the Clinical Bioinformatics Ontology (CBO) aims to provide uniquely identified concepts to include molecular pathology terminologies. Since individual genome data are easily used to predict current and future health status, different safeguards to ensure confidentiality should be considered. In this paper, we focused on the informatics aspects of integrating the EMR community and BI community by identifying opportunities, challenges, and approaches to provide the best possible care service for our patients and the population.

숙종의 두창(痘瘡)에 관한 『승정원일기(承政院日記)』의 의안(醫案) 연구 (A study on the Clincal Records of 『The daily Records of Royal Secretariat of Chosun Danasty』)

  • 고대원;김동율;김태우;차웅석
    • 한국의사학회지
    • /
    • 제25권1호
    • /
    • pp.43-51
    • /
    • 2012
  • Smallpox and measles might be the typical epidemics through Choson Danasty. Especially Sookjong was the first king who suffered from smallpox during the period of his reign. This study was examined critically focused on the Clinical Records about Smallpox which occurred in the 9th year of Sookjong's reign. The clinical records in Seungjeongwon Ilgi("承政院日記") was the main source and the Annals of the Joseon Dynasty was reffered. It tells us that Sookjong caught infectious disease, smallpox spread in town and the whole process of smallpox. Seungmagalgeuntang(升麻葛根湯) and hwadoktang(火毒湯) were given at the early term for treating Sookjong's smallpox, but later on, Bowontang(補元湯) was given for the treatment of smallpox. It showed us the medical view which placed emphasis on the vital force of human body. A dermatologist, Yoo Sang had joined since the beginning of the treatment and Siyakchung(侍藥廳) was established for Sookjong. Sasunghoichuntang(四聖回天湯) which was Chunyoohyung(全有亨)'s prescription showed us enough clinical experience and the ways of treatments. At the same time, the medical culture at that time was well known through the fact that smallpox was taboo among the royal family.

현종 비 명성왕후의 복약 기록 연구 - 『승정원일기』의 의안을 중심으로 - (A Study on Clinical Records of King Hyeonjong's Queen, Queen Myeongseong, Focusing on Cases Recorded in the Seungjeongwon Ilgi (The Daily Records of Royal Secretariat of Joseon Dynasty 承政院日記))

  • 박주영;국수호;김남일;차웅석
    • 한국의사학회지
    • /
    • 제32권1호
    • /
    • pp.11-20
    • /
    • 2019
  • Queen Myeongseong was the wife of King Hyeonjong, the 18th king of the Joseon Dynasty, and the mother of King Sukjong. The clinical records of Queen Myeongseong are summarized on the basis of the Seungjeongwon Ilgi (The Daily Records of Royal Secretariat of Joseon Dynasty 承政院日記) and reviewed through Donguibogam. Queen Myeongseong gave birth to one male and three female children in the time of the queen. She took Geumgaedangguihwan (金櫃當歸丸), Dalsaengsan (達生散), Antaeum (安胎飮) during her pregnancy and Gungguitang (芎歸湯) during postnatal care. Since 1669, chest tightness, sleeplessness, arm pain and numbness of arms had been appeared. Ondamtang (溫膽湯) and Dodamtang (導痰湯) were used but they were not effective. However, when her symptoms were regarded as a benign tumor due to cold and wetness, there was a difference in the use of Ohjuksan (五積散). In 1683, when king Sukjong was caught in a smallpox, she took care of him. She exorcised in the middle of winter to pray for her son's recovery, and died of the flu.

임상용어의 의미적 상호운영성을 위한 매핑 도구 (Mapping Tool for Semantic Interoperability of Clinical Terms)

  • 이인근;홍성정;조훈;김화선
    • 전기학회논문지
    • /
    • 제60권1호
    • /
    • pp.167-173
    • /
    • 2011
  • Most of the terminologies used in medical domain is not intended to be applied directly in clinical setting but is developed to integrate the terms by defining the reference terminology or concept relations between the terms. Therefore, it is needed to develop the subsets of the terminology which classify categories properly for the purpose of use and extract and organize terms with high utility based on the classified categories in order to utilize the clinical terms conveniently as well as efficiently. Moreover, it is also necessary to develop and upgrade the terminology constantly to meet user's new demand by changing or correcting the system. This study has developed a mapping tool that allows accurate expression and interpretation of clinical terms used for medical records in electronic medical records system and can furthermore secure semantic interoperability among the terms used in the medical information model and generate common terms as well. The system is designed to execute both 1:1 and N:M mapping between the concepts of terms at a time and search for and compare various terms at a time, too. Also, in order to enhance work consistency and work reliability between the task performers, it allows work in parallel and the observation of work processes. Since it is developed with Java, it adds new terms in the form of plug-in to be used. It also reinforce database access security with Remote Method Invocation (RMI). This research still has tasks to be done such as complementing and refining and also establishing management procedures for registered data. However, it will be effectively used to reduce the time and expenses to generate terms in each of the medical institutions and improve the quality of medicine by providing consistent concepts and representative terms for the terminologies used for medical records and inducing proper selection of the terms according to their meaning.

청강진요부 자료현황 보고 - 입수경위와 정리현황 및 연구적 가치 - (A paper on the Present Condition of Cheong-Gang (청강) Medical Chart -Means of Acquisition, Filing Condition and Research Value)

  • 차웅석
    • 대한한의학회지
    • /
    • 제25권2호
    • /
    • pp.119-126
    • /
    • 2004
  • Introduction : Kim-Young-hun (김영훈), with the pen name of Cheong-Gang (청강), was born in the late 19th century. He led an active life as an eminent Korean traditional medical scholar until the mid-20th century. He opened a Korean traditional medical clinic in the heart of Seoul and kept records of his clinical experiences. Methods : Filing of clinical records: Cheong-Gang's records, at present owned by the College of Oriental Medicine, Kyunghee University (경희대학교 한의과대학), are classified into prescription charts and medical examination charts. In this study, only the medical examination charts were filed. Results : The total number of the medical examination charts from 1915 until 1974 is 393, and the titles are sorted according to date. This paper is the first filing research on the medical examination charts.

  • PDF