• Journal of Digital Convergence
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• v.11 no.6
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• pp.245-256
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• 2013

This study was conducted in order to examine the quantity of health and medical statistics survey in Medical Records Offices which was required by outside institutions and whether it is profitable for the hospitals or not. The thirteen outside institutions required health and medical statistics of the 24 types of the survey to Medical Records Offices. 16.7% of health and medical statistics of the survey was paid to medical records offices such as the National Cancer Registration Survey, Patient Survey, Tuberculosis Patient Survey, and Hospital Discharge Patients Injury Survey. Medical Records Offices' total length of time for the health and medical statistics survey was over 200 hours per year like the National Cancer Registration Survey, Healthcare Accreditation System and Hospital Discharge Patients Injury Survey. The Medical Record Administrators in the hospitals with fewer than 500 beds work full time from 1 to 3. It is indicated in the study that it is necessary to improve the health and medical statistics survey system in Medical Records Offices required by the outside institutions and to employ additional Medical Record Administrator for more accurate Health and Medical Statistics Survey.

• Quality Improvement in Health Care
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• v.6 no.1_2
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• pp.80-91
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• 1999

Background : With the CQI concepts, which emphasize doing the right things right the first time, we tried to enhance the timely completion of medical records by changing the review process from retrospective method to concurrent one. Methods : Against the current retrospective QA activity, Medical record administrator did the concurrent QA of the inpatient medical records with the deficiency sheets. One general surgery ward was chosen as a trial one. The deficiency rate of the medical records of the discharged patients was compared before and after the enforcement of the system. Job analysis of the medical record departments was done about four tertiary care hospitals located in Seoul to estimate the cost and the time consumed by current system. Results : There was a little improvement in the completion rate of the medical records after the trial. The new system was effective. And job analysis showed that much money and time were wasted by current retrospective feedback system. Conclusion : Though the result was not so satisfactory, it should be considered that this test was a voluntary one and the interns and residents were not forced to complete the medical records during this trial period. If there be any strong motivation to complete the medical record in time, this system is sure to be succeed. As the DRG system requires the concurrent review of the medical records to confirm severity of the patient's illness and to assure the timely discharge, it is desirable to enforce this method with the DRG system together. DRG coding and reducing deficiency rate of the medical records can be accomplished simultaneously.

• Quality Improvement in Health Care
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• v.5 no.1
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• pp.16-26
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• 1998

Background : As many previous studies proved, the quality of medical record is thought to reflect the quality of care. In this study, we analyzed the relationship between the quality of record and some factors influencing the quality of record, especially the commitment of the attending physician. Method : We developed checklist for evaluation of medical record with 36 criteria. 300 inpatient records of 10 attending physicians' patients were evaluated and the quality' of records were scored. The attending physician's commitment to medical records were scored by 34 residents. The relationship of the quality of records with physician's commitment to records, and some other factors were analyzed. Results : More than 75% of the immediate postoperative notes on the progress note were missed. More than 69% of the contents of explanation about the procedures on the consent form or on the other forms were also missed. The physician whose quality score of records was the highest(78.9) got the highest commitment score. The score of attending physician's commitment to the record, and his seniority were positively related with the quality score of his medical records when number of patients and department were adjusted. Conclusion : The quality of the 5 forms of the record reviewed were evaluated as moderate or excellent except 2 or 3 items. The quality of record was positively related with the attending physician's commitment to the record, and the seniority of the physician.

• KSII Transactions on Internet and Information Systems (TIIS)
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• v.11 no.7
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• pp.3699-3719
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• 2017

Conjunctive keyword search encryption is an important technique for protecting sensitive personal health records that are outsourced to cloud servers. It has been extensively employed for cloud storage, which is a convenient storage option that saves bandwidth and economizes computing resources. However, the process of searching outsourced data may facilitate the leakage of sensitive personal information. Thus, an efficient data search approach with high security is critical. The multi-user search function is critical for personal health records (PHRs). To solve these problems, this paper proposes a novel multi-user conjunctive keyword search scheme (mNCKS) without a secure channel against keyword guessing attacks for personal health records, which is referred to as a secure channel-free mNCKS (SCF-mNCKS). The security of this scheme is demonstrated using the Decisional Bilinear Diffie-Hellman (DBDH) and Decision Linear (D-Linear) assumptions in the standard model. Comparisons are performed to demonstrate the security advantages of the SCF-mNCKS scheme and show that it has more functions than other schemes in the case of analogous efficiency.

• Asian Pacific Journal of Cancer Prevention
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• v.14 no.3
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• pp.2107-2111
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• 2013

Objectives: To investigate data agreement of cancer registries and medical records as well as the quality of care and assess their relationship in a 5-year period from 2006 to 2011. Methods: The present cross-sectional, descriptive-analytical study was conducted on 443 cases summarized through census and using a checklist. Data agreement of Nemazi hospital-based cancer registry and the breast cancer prevention center was analyzed according to their corresponding medical records through adjusted and unadjusted Kappa. The process of care quality was also computed and the relationship with data agreement was investigated through chi-square test. Results: Agreement of surgery, radiotherapy, and chemotherapy data between Nemazi hospital-based cancer registry and medical records was 62.9%, 78.5%, and 81%, respectively, while the figures were 93.2%, 87.9%, and 90.8%, respectively, between breast cancer prevention center and medical records. Moreover, quality of mastectomy, lumpectomy, radiotherapy, and chemotherapy services assessed in Nemazi hospital-based cancer registry was 12.6%, 21.2%, 35.2%, and 15.1% different from the corresponding medical records. On the other hand, 7.4%, 1.4%, 22.5%, and 9.6% differences were observed between the quality of the above-mentioned services assessed in the breast cancer prevention center and the corresponding medical records. A significant relationship was found between data agreement and quality assessment. Conclusion: Although the results showed good data agreement, more agreement regarding the cancer stage data elements and the type of the received treatment is required to better assess cancer care quality. Therefore, more structured medical records and stronger cancer registry systems are recommended.

• Quality Improvement in Health Care
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• v.4 no.2
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• pp.174-183
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• 1997

Background : Medical records thought to be reflecting the quality of medicine. By this ground, examination of medical records can be served to evaluate, and to improve the quality of medical care. To examine the medical records, we need some standards or checklists which can be used to sort out the problems. Methods: We developed checklists for medical records evaluation. We studied 1,677 medical records about its completeness using this checklists in one educational hospital. Survey was completed by 5 well trained staffs of medical record department. Results are analyzed. SPSS/PC+ program was used for statistics. Results : 13.8% of discharge summary was incomplete. Recording of the demographic information was also poor in incomplete medical records compared to complete ones. Progress note was recorded average 4.16 times during 11.9 hospital days. After 4th hospital day, recording rate of progress note dropped sharply. Rate of professor's signature on operation records was poor(27%). He or she who described the discharge summary well also wrote progress note well. Conclusions: Fill-up of demographic date should be stressed during medical record education program. Strategy to create the environment emphasizing the responsibility of professor on quality medical record should be made. We suggest new index (number of records/hospital stay) for the evaluation of completeness of progress note.

• Journal of muscle and joint health
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• v.26 no.1
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• pp.27-34
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• 2019

Purpose: This study was done to analyze nursing assessment and nursing care for pain in the electronic nursing records for the elderly patients with abdominal pain visiting the Emergency Medical Center. Methods: This study is a descriptive study based on nursing records from January to December 2015. A total of 1155 records for elderly patients with abdominal pain were gathered. Results: The mean age of elderly patients whose records were analyzed was 75.2 years. Analysis of nursing records regarding pain management showed that semi-urgent severity (93.7%), direct emergency room visits (58%), and 6.01 hours of emergency room stay (6.01 hours)were the most frequently documented characteristics of the elderly patients with pain complaints. Recording time of nursing assessment for abdominal patients was 1.01 hour; the average pain intensity was 3.97. The mostly used nursing intervention for abdominal pain was medication (65.1%). There was no record of non-pharmacological pain nursing interventions. Conclusion: The results of this study showed that improving knowledge and nursing practice for pain management is much of necessity. In particular, development of the non-pharmacological nursing interventions for pain is needed. Further research is also imperative to develop and evaluate record systems for pain management that can be used in the emergency room.

• Research in Community and Public Health Nursing
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• v.9 no.2
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• pp.303-312
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• 1998

The purpose of this study was to survey the knowledge level, attitude and practice of nurses toward their work. The subjects of the study were composed of 98 nurses from 3 general hospitals, 1 oriental medical hospital, 2 health centers and several community health posts and schools. Data were collected from May to October, 1998. In data analysis, an SPSS PC program was utilized for descriptions. 1) 16 nurses (16.3%) experienced medical accidents on the 7 nurses(7.1%) 1 time, 6 nurses (6.1%) 2 times, and 3 nurses(3.1%) 3 times. 2) Concerning knowledge of their legal obligations ; the prohibition of telling secrets was .89, the prohibition of reading medical records was .58, the keeping of medical records was 1.0 and the teaching of recuperation was. 79. The total mean score was. 86. Concerning attitude and practice; the prohibition of telling secrets was 81.6%, 63.3%. The prohibition of reading medical records was 61.2%, 60.2%. The keeping of medical records was 98%, 98%. The explanation for treatment, care and test was 91.8%, 66.3%. The teaching for recuperation was 63.3%, 63.3%. 3) Knowledge of their legal responsibilities; 29. 6% of the subjects thought that they should report a medical accident to their headnurse, but 75.5% of the subjects actually reported to the headnurse. 39.8% of the subjects thought that nurses were liable for the faults of nursing aides. The total mean score was .45. 46% of the subjects asked a senior staff's advide on difficult affairs. Nurses obeyed legal obligations when concern ing the protection of a client, but were passive when concerning self protection. Also, headnurses were required as adviser, guide and advocate.

• Journal of Korean Society of Occupational and Environmental Hygiene
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• v.23 no.4
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• pp.367-373
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• 2013

Objectives: Employee exposure record refers to a record containing information about environmental (workplace) monitoring or measuring of a toxic substance or harmful physical agent. The aims of this study were to examine problems related to exposure records and provide some amendments to the Korean Industrial Safety & Health Act for the effective management of chemical substances under the law. Methods: This study performed a literature search and review on legal provisions related to exposure records of a number of different countries, including Korea, the USA, Japan, EU, Germany, and the UK. They were compared and investigated and the amendment of articles was suggested. Results: The results of this study were provided as suggested amendments to the related act. There were a variety of ways of improvement, including a 30-year retention period and the introduction of new access methods, contents, transfer, and maintenance methods. All exposure data elements have to be standardized, including reference to a similar exposure group (SEG), sampling strategy, and circumstances of exposure (e.g., date, shift length, use of personal protective equipment, etc.). The SEGs are described by process, job, task, and environmental agent. Conclusions: This study is expected to provide for the amendment of the related act in order to ensure effective management of exposure records and is helpful for solving the cause and result of occupational disease by keeping exposure records according to the Industrial Safety & Health Act.

• Safety and Health at Work
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• v.9 no.1
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• pp.109-114
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• 2018

Background: Although work absenteeism is in the focus of occupational health, longitudinal studies on organizational absenteeism records in hospital work are lacking. This longitudinal study tests time pressure and lack of time autonomy to be related to higher sickness absenteeism. Methods: Data was collected for 180 employees (45% nurses) of a Swiss hospital at baseline and at follow-up after 1 year. Absent times (hours per month) were received from the human resources department of the hospital. One-year follow-up of organizational absenteeism records were regressed on self-reported job satisfaction, time pressure, and time autonomy (i.e., control) at baseline. Results: A multivariate regression showed significant prediction of absenteeism by time pressure at baseline and time autonomy, indicating that a stress process is involved in some sickness absenteeism behavior. Job satisfaction and the interaction of time pressure and time autonomy did not predict sickness absenteeism. Conclusion: Results confirmed time pressure and time autonomy as limiting factors in healthcare and a key target in work redesign.