• Title/Summary/Keyword: Doctor's note

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Development of Records for Home Hospice Care Team (기정 호스피스 팀 기록지 개발)

  • Lee, Jong-Eun;Han, Sung-Suk;Park, Chai-Soon;Yoo, Yang-Sook;Choe, Sang-Ok;Lee, Mi-Song;Kim, Seong-Eun;Lee, Sun-Mi
    • Journal of Hospice and Palliative Care
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    • v.11 no.1
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    • pp.12-29
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    • 2008
  • Purpose: To develop the standardized record forms for home hospice team members, made up of nurse, doctor, social worker, minister and volunteer, to share information and communicate efficiently in their specialized field. Methods: A methodological study revising and complementing initially developed record forms by obtaining content validity from the experts in each field. Results: Reflecting total 27 experts' opinions, final 11 types of home hospice team documents (registration form, visiting record form for a nurse, initial assessment form for a doctor, progress note for a doctor, initial assessment form for spiritual care, visiting record form for a minister, care note for social worker, visiting record form for a volunteer, final summary note, initial assessment form for bereaved family, and follow-up record form for bereaved family) have been developed. Conclusion: It is believed that this study initiated of effective communication between home hospice team members and enhanced quality of home hospice service and its records.

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The Necessity for a Trauma Surgeon and the Trauma Surgeon's Role in the Trauma Care System (외과의사 관점에서 외상전문의의 필요성과 과제)

  • Lee, Kug Jong
    • Journal of Trauma and Injury
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    • v.21 no.1
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    • pp.1-7
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    • 2008
  • When man first walked on this planet, injury must have been a close encounter of the first kind. The outbreak of World War I, during a period of rapid scientific growth in the basic sciences, demonstrated the need to develop better methods of care for the wounded, methods that were later applicable to the civilian population. Trauma is a multisystem disease and, as such, benefits from almost any advance in medical science. As we learn more about the physiology and the biochemistry of various organ systems, we can provide better management for trauma victims. Improved imaging techniques, better appreciation of physiologic tolerance, and increased understanding of the side effects of specific surgical procedures have combined to reduce operative intervention as a component of trauma patient care. On the other hand, because of this rapid development of medical science, only a few doctors still have the ability to treat multisystem injuries because almost doctor has his or her specialty, which means a doctor tends to see only patients with diagnoses in the doctor's specialty. Trauma Surgeons are physicians who have completed the typical general surgery residency and who usually continue with a one to two year fellowship leading to additional board certification in Surgical Critical Care. It is important to note that trauma surgeons do not need to do all kinds of operations, such as neurosurgery and orthopedic surgery. Trauma surgeons are not only a surgeon but also general medical practitioners who are very good at critical care and coordination of patient. In order to achieve the best patient outcomes, trauma surgeons should be involved in prehospital Emergency Medical Services, the Trauma Resuscitation Room, the Operating Room, the Surgical Intensive Care and Trauma Unit, the Trauma Ward, the Rehabilitation Department, and the Trauma Outpatient Clinic. In conclusion, according to worldwide experience and research, the trauma surgeon is the key factor in the trauma care system, so the trauma surgeon should receive strong support to accomplish his or her role successfully.

A Case Study of Home Health Care for Postpartum Women and their Newborns (산욕부와 신생아의 가정간호 사례연구)

  • Jun, Eun-Mi
    • 모자간호학회지
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    • v.4 no.1
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    • pp.3-11
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    • 1994
  • Presently there is an increasing demand for home health care services due to changes in the demographic structure as a result of an increasing elderly population, socio-economic improvements, and changes in the family structure, as well as the growing number of people with degenerative diseases. In addition to these reasons, rising medical costs and there a shortage of patient beds space in the hospital, particularly since introduction of national medical insurance. There has been an increasing demand for health care health care services. This study was done to identify the basic data for home health care management. It focused on developing client selection criteria, assessment tools, and recording methods. This was accomplished by the researchers visiting the patients in their homes. The research process included preparation investigation, tool development, training of the project researcher, and visiting the clients in their homes. The research tools are as follows : 1. Record development : a) The selection criteria tool for home health care of postpartum women was a structured tool and consisted of four parts. b) The structured assessment tool consisted of a general items, obstetric history, past medical history, methods of feeding, medications taken before admission, laboratory test results, discharge instructions, discharge medications, family tree, economic status, environmental status, a map, health assessment of postpartum women and their newborns. c) The visit note I consisted of the frequency of visits. Visit note II consisted of the date ; nursing problems ; nursing process including the initial assessment ; nursing goal ; visit plan ; postpartum women and their neonate health status, diagnosis, goal, implementation, evaluation, summary, next plan, for visit revision. d) Problem note consisted of the date, problem numbers, nursing diagnosis, problem appearance date problem resolution date. The research results are as follows : 1. Nursing problems : The nursing problems of the postpartum women and their neonates were evaluated by the number of nursing diagnoses and the change in the pattern of nursing diagnosis related to the number of visits. a) Nursing diagnosis The nursing diagnosis was classified according to physical function, psychosocial function, family system maintained function. b) The changes of nursing diagnosis related to the number of visits. As the type of nursing diagnosis changed related to the number of visits the number of nursing diagnoses decreased. 2. Contents of home health care : The content was categorized according to assessment, direct care, counseling, education, family care, reporting to with the attending doctor. The recommendations based on the research results are as follows : 1. Tool development Replication of this study is needed to test the validity of the assessment tools used. 2. Home visit a) Home health care nurses should be licensed and qualified. A referral form from the attending doctor is needed for legal protection of nurses. b) The first home visit need to be within 24 hours of discharge from the hospital to decrease the anxiety of frightened postpartum women. c) When the changes occur in the newborn's status, home health care nurses should consult a pediatrician. Communication within the home healthcare team is essential and needs to consistent and done smoothly. 3. Home health care A Study is required to develop protocols for education of staff and for operation of all aspects of this program.

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A Study on Physical Therapy Patients (물리치료 환자에 대한 실태조사 연구)

  • Park Youn-ki
    • The Journal of Korean Physical Therapy
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    • v.2 no.1
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    • pp.9-20
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    • 1990
  • This study researched 1,408 physical therapy patients in hospital. orthopedic clinic. neurosurgical clinic, general surgical clinic, and general clinic located Taegu city on may 9. 1990. Also this study reviewed front doctor's prescripted progress note. The results obtained were as followed. 1) 4th decade of age $(22\%)$ are the highest, and 3rd, 2nd, 5th decade were followed. Many dorsopathies are not correlated with age, also they involved 2nd decade age and 3rd decade are sprain and strains of joints and adjacent muscle. 4th and 5th decade of age are rheumatism. 2) According to medical facility. They treated in hospital are other disorders of central nervous system. orthopedics are rheumatism, and in neurosurgical clinic. general surgical clinic, general clinic are dorsopathies. 3) Male and female both have a lot of dorsopathies, sprains and strains of joint and adjacents muscle occurred in males, female have a lot of rheumatism. 4 At physical therapy patients, $21.4\%$ patients are in patients and others are out patients. Among the $66.1\%$ of on patients, they treated in hospital as they have other disorders of central nervous system.

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Breast Cancer Detection with Thermal Images and using Deep Learning

  • Amit Sarode;Vibha Bora
    • International Journal of Computer Science & Network Security
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    • v.23 no.8
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    • pp.91-94
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    • 2023
  • According to most experts and health workers, a living creature's body heat is little understood and crucial in the identification of disorders. Doctors in ancient medicine used wet mud or slurry clay to heal patients. When either of these progressed throughout the body, the area that dried up first was called the infected part. Today, thermal cameras that generate images with electromagnetic frequencies can be used to accomplish this. Thermography can detect swelling and clot areas that predict cancer without the need for harmful radiation and irritational touch. It has a significant benefit in medical testing because it can be utilized before any observable symptoms appear. In this work, machine learning (ML) is defined as statistical approaches that enable software systems to learn from data without having to be explicitly coded. By taking note of these heat scans of breasts and pinpointing suspected places where a doctor needs to conduct additional investigation, ML can assist in this endeavor. Thermal imaging is a more cost-effective alternative to other approaches that require specialized equipment, allowing machines to deliver a more convenient and effective approach to doctors.

A Study on the Decision Point and a Standard of Judgment under the Duty of Inter-hospital Transfer for Patients of Doctor - Focused on the Trend of Supreme Court's Decisions - (의사의 전원의무(轉院義務) 위반 여부의 판단기준과 전원시점 판단 - 판례의 동향을 중심으로 -)

  • Choi, Hyun-tae
    • The Korean Society of Law and Medicine
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    • v.20 no.1
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    • pp.163-201
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    • 2019
  • Doctor has the duty of an inter-hospital transfer, known as inter-facility or secondary transfer, when the diagnostic and therapeutic facilities required for a patient are not available at the given hospital. Also, the decision to transfer the patient to an another facility is rely on whether ill patient is the benefits of care, including clinical and non-clinical reasons, available at the another facility against the potential risks. Crucial point to note is that issues about 'inter-hospital transfer' is limited to questions occurred in the course of transfer between emergency medicals (facilities). 'emergency medical (facility)' is specified by Medical Law, article 3 and the duty of an inter-hospital transfer includes any possible adverse events, medical or technical, during the transfer. Because each medical facility has an different ability to care for a patient in an emergency condition, coordination between the referring and receiving hospitals' emergency medicals would be important to ensure prompt transfer to the definitive destination avoiding delay at an emergency. Simultaneously, transfer of documents about the transfer process, medical record and investigation reports are important materials for maintaining continuity of medical care. Although the duty of an inter-hospital transfer is recognized as one of duty of doctor and more often than not it occurs, there is constant legal conflict between a doctor and a patient related to the duty of the inter-hospital transfer. Therefore, we need clear and specific legal standard about the inter-hospital transfer. This paper attempts to review the Supreme Court's cases associated to the inter-hospital transfer and to compare opinion of the cases with guideline for an inter-hospital transfer already given. Furthermore, this article is intended to broaden our horizons of understanding the duty of an inter-hospital transfer and I wish this article helps to resolve the settlement and case dealt with the duty of inter-hospital transfer.

Review of 2017 Major Medical Decisions (2017년 주요 의료판결 분석)

  • Lee, Jung Sun;Lee, Dong Pil;Yoo, Hyun Jung;Jeong, Hye Seung;Park, Tae Shin
    • The Korean Society of Law and Medicine
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    • v.19 no.1
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    • pp.207-254
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    • 2018
  • The major court rulings delivered in 2017 include the ruling that separated the legal character of denture production agreement signed together with medical care agreement and found a subcontracting dimension in the former, and the ruling that overcame the limitations of the theory of entire appearance of a fetus as discussed in civil law by using the legal principle of insurance which suggests that unborn child insurance takes effect after the contract is signed and the first installment of the premium is paid in. As more court rulings find the medical specialists responsible for accidents and injuries from drugs, some argue that medication counseling by the druggist who makes and dispenses drugs should be upgraded. And with respect to a court ruling that denied the hospital's responsibility for an infection-involving accident even if there were no records on specific measures taken in infection management, some criticized the court for being too conservative in recognizing responsibilities. And with respect to infectious disease management, some criticized the court for its interpretation and application of the facts in the direction of denying the negligence. In addition, some claimed that it is necessary to establish institutional system for hospital infection control and its aid for victims, and to improve the system including the reversal of the burden of proof given the special nature of hospital infections. A number of rulings on the duty to disclose included the one which stated that the specific matter did not require a doctor's explanation as it was explained or the specific medical service would have been performed even if no explanation had been given. There was a greatly controversial ruling over the scope of indemnification, which accepted the occurrence of multiple scars and deformation as disorders while regarding breast as a thoracic organ. And a Supreme Court ruling over interpreting Medical Service Act was criticized as overstepping the boundary allowed in the law.

Expert Testimony in Litigation of Sexual Violence against People With intellectual disabilities (지적장애인 성폭력 사건 재판에서 전문가 참여제도 활용 실태)

  • Yi, Mi Sun
    • Korean Journal of Forensic Psychology
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    • v.12 no.1
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    • pp.1-13
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    • 2021
  • This study analyzed the use of expert reports in the investigations and trials of cases of sexual violence against people with intellectual disabilities. A total of 670 alleged sexual assault cases against victims with intellectual disabilities were analyzed. Results showed that 97.5% of the cases included at least one expert report. In most cases(91%), the expert reports of statement validity assessment were included. Additionally, doctor's note (41.1%) from obstetricians and Psychiatrists, intermediary reports(36%), and expert witnesses(psychologists') reports (9.5%) were included. In 80 cases (44.4%) of the 180 cases in which a victim' statement credibility was in question during the trial, judges cited the expert's reports of statement validity assessment as the basis for the judgment on the reliability of the victims' accusation. The frequency of citing the report was higher when the victim was under the age of 13, or when the defendant was found guilty. Regrading the report content, the evaluations of criteria-based content analysis(CBCA) was most frequently cited, while the victim's psychological status, cognitive limitation, as well as possibile contamination of victim's account, were also mentioned in the ruling statements. Results showed agreement between experts' statement validity assessments and judges' determinations in 79 cases out of the 80 cases Finally, this study discussed ways to utilize expert options.

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Characteristics of Middle School Students in a Biology Special Class at Science Gifted Education Center: Self-regulated Learning Abilities, Personality Traits and Learning Preferences (과학영재교육원 생물반 중학생들의 특성: 자가조절학습능력에 따른 개인적 성향 및 학습선호도)

  • Seo, Hae-Ae
    • Journal of Gifted/Talented Education
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    • v.19 no.3
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    • pp.457-476
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    • 2009
  • The research aimed to investigate characteristics of middle school students in a biology class as science gifted education in terms of self-regulated learning abilities, personality traits and learning preferences. The twenty subject in the study responded to questionnaires of a self-regulated learning ability instrument, a personality trait tool, and a learning preference survey in March, 2009. It was found that the research subjects showed higher levels of cognitive strategies, meta-cognition, and motivation than those students in a previous study(Jung et. al., 2004), while environment was opposite. The level of cognitive strategies was significantly correlated with meta-cognition(r=.610, p=.004) and motivation (r=.538, p=.014) and meta-cognition with environment(r=.717, p=.000). Those students who showed highest levels of self-regulated learning ability displayed various personality traits. One male student with the highest level of self-regulated learning ability showed a personality of hardworking, tender-minded, and conscientious traits and wanted to be a medical doctor. The female student with the second highest level of self-regulated learning ability presented a personality as creative, abstract and divergent thinker and she showed a strong aspiration to be a world-famous biologist with breakthrough contribution. The five students with highest levels of self-regulated learning ability showed a common preference in science learning: they dislike memory-oriented and theory-centered lecture with note-taking from teacher's writings on chalkboard; they prefer science learning with inquiry-oriented laboratory work, discussion among students as well as teachers. However, reasons to prefer discussion were diverse as one student wants to listen other students' opinions while the other student want to present his opinion to other students. The most favorable science teachers appeared to be who ask questions frequently, increase student interests, behave friendly with students, and is a active person. In conclusion, science teaching for the gifted should employ individualized teaching strategies appropriate for individual personality and preferred learning styles as well as meeting with individual interests in science themes.