• 제목/요약/키워드: Medical Record Administrator

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의무기록 완성도에 대한 병동순회 의무기록사제도의 개입효과 (A Study on the Ward Rounding System of Medical Record Administrator for Improving the Completeness of the Medical Records)

  • 강선희;박훈기;이금순;문옥륜;정풍만
    • 한국의료질향상학회지
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    • 제6권1_2호
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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.

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부산·경남지역 의무기록사 직무분석 (A Study on the Job Description of Medical Record Administrator in Busan and Gyeongnam)

  • 정미영;김혜숙;김경나
    • 보건의료산업학회지
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    • 제6권4호
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    • pp.61-72
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    • 2012
  • The purpose of this study was to propose how to improve and develop the college curriculum of medical record administration, satisfying requirements from hospitals having medical record administrators. For the purpose, this researcher surveyed medical record administrators serving at hospitals located in Busan, Changwon, Masan and Jinju. Finally analyzed were responses from 100 medical recorders. The frequency of searching medical records to support information use was statistically different among hospitals according to the number of sick beds(p=.041), or $3.16{\pm}1.75$ for fewer than 300 sick beds, $4.28{\pm}2.42$ for 300 to 500 and $4.86{\pm}3.18$ for more than 500. The college course that was regarded as most important by most of the surveyed medical record administrators, or 53(37.2%) was medical terminology, followed by statistics by 36 of the respondents(18.5%) and EMR, 25(12.8%) in order. To make EMR truly effective requires reforming the university curriculum of medical record administration and giving more attention and more supports to training for better computerization, realizing that medical record administrators serve as a true manager of health and medical information, not a person who just paper-based medical information. In addition to managing health and medical information, medical record administrators are expected to have more roles in the future, for example, providing high-quality clinic knowledge and medical information that are necessary for efficient hospital management and medical research to survive competition.

병원직원의 갈등과 환자에 대한 태도 (Hospital Employees' Conflict and Attitude Toward Patients)

  • 신점순;박재용;감신;주리
    • 한국병원경영학회지
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    • 제2권1호
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    • pp.114-136
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    • 1997
  • This study was carried out to find out the effect of conflict between profession groups within medical institution. For the purpose, the questionnaire-based research was done with 605 persons consisting of specialists, residents, nurses, radiologic technicians, clinicopatholigic technicians, health record administrator, administrative employees who are working in a university hospital located in Taegu City from February 15, 1997 to March 2, 1997. The results of the study were summarized as follows. The subject profession group against which each profession group feels the most conflict in interprofession mutual recognition relation was found out as follows; Specialists(34%) against colleague specialists, residents(54.0%) against nurses, nurses(54.8%) against residents, radiologic technicians(44.0%) against residents, and clinicopathologic technicians(34.5%) against nurses, while it was shown that health record administrator felt even conflict against residents, nurses and administrative employees and administrative employees(48.1) did against nurses. Most employee group answered that medical specialists have a one-sided and individual attitude toward all affairs, while both medical specialists and administrative employees of hospital answered that nurses are one-sided. It was shown among such groups that radiologic technicians' conflict results from their thinking which mutual dependence and cooperation are lowest while individual difference is highest, clinicopatholigic technicians' conflict from the problem in mutual communication, medical specialists' conflict from difference in goals greater than other group, respectively lower than other group. The rate of vertical conflict between groups was highest for the health record administrators and then for the radiological technicians, while it was lowest for the medical specialists and then for the nurses. In addition, the rate of horizontal conflict was high for both medical specialists and nurses, but it was low for the health record administrations and clinicopathological technicians. The group with the highest job satisfaction was the medical specialists and nurses, and the group with the highest involvement in organization was the medical specialists and administrative employees. Also it was shown that both medical specialists and clinicopathological technicians show a favorable attitude toward patients. Factors having an effect on the vertical conflict included difference in goals, cooperation within group and leadership. It was shown among those factors, however, that only the leadership has an effect on all the groups evenly. The horizontal conflict was influenced by such factors as educational level, mutual dependence, difference in goals, cooperation within group, and individual difference, when an important factor was the difference in goals for all the groups. Their attitude toward patients was influenced by the vertical conflict and age, but the vertical conflict was the most significant factor for the medical specialists. In conclusion, it is required to control properly the conflict between employees as well as between profession group and to execute good leadership, so as to improve patients' satisfaction which is the key goal of hospital.

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의무기록부서의 외부기관 통계지원 업무에 관한 연구 (The health and medical statistics survey in Medical Records Offices required by the outside institutions)

  • 임복희;유진영
    • 디지털융복합연구
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    • 제11권6호
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    • pp.245-256
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    • 2013
  • 본 연구에서는 의무기록부서에서 외부기관에 제공하고 있는 보건의료통계 사업의 종류와 업무 소요시간 그리고 그에 따른 병원의 수익성 여부를 구체적으로 파악하고자 하였다. 의무기록부서는 13개 외부기관으로부터 24종류의 보건의료통계조사 사업과 관련한 통계생산 작성 제출 요청을 받고 있는 것으로 나타났다. 조사비용 지불률은 16.7%로, 암등록사업, 환자조사, 결핵환자조사, 퇴원손상환자조사만이 의무기록부서(병원)에 보건의료통계 생산 작성 제출에 대한 비용 지불을 하고 있었다. 의무기록부서는 암등록사업, 의료기관인증제, 퇴원손상환자조사에 각각 200시간 이상의 업무처리 시간이 소요되고 있었으며 500병상 미만의 병원의 경우 1~3명의 정규직 의무기록사가 병원 의무기록실에 근무하고 있는 것으로 나타났다. 외부기관으로부터 요구되는 보건의료통계 사업에 대한 전반적인 시스템 개선이 필요하며, 보다 정확한 보건의료통계 생산을 위해 의무기록사 인력확보가 필요하다 여겨진다.

첨단센서를 활용한 시약장 관리 시스템 (Reagent storage management system using advanced sensors)

  • 장재명;이종원;박상노;김창수;정회경
    • 한국정보통신학회:학술대회논문집
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    • 한국정보통신학회 2016년도 추계학술대회
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    • pp.790-791
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    • 2016
  • 의료, 화학 분야의 연구실에서 사용되는 시스템은 일반적으로 내부 온도만 측정하여 보관하고 내부의 시약 관리를 수기로 기록한다. 이로 인해 시약 보관 시 내부에서 발생하는 문제를 실시간으로 인식하지 못해 사고가 발생하고 시약 보관 시 사용 기록이 누락되어 효율적인 시약 관리에 대한 문제점이 대두되고 있다. 본 논문에서는 이를 해결하기 위해 실험실에서 임베디드 보드와 센서를 활용해 시약을 효과적으로 관리하는 시약 관리 시스템을 제안한다. 이를 위해 NFC(Near Field Communication)를 이용해 시약의 정보를 데이터화 하여 관리자가 위험 시약을 등록 및 관리하고, 시약 사용자를 식별 할 수 있으며, 온도, 습도, VOC 센서들을 활용하여 제어하게 한다. 또한 특정 위험 상황 발생 시 관리자에게 메시지를 전달하여 알려준다. 이는 실험실에서 효율적인 시약 관리를 가능하게 할 것으로 사료된다.

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진료재료대 수가누락방지 및 비용절감 개선활동 (Prevention of Missing the Fee of Medical Supplies and Improvement Activity of Cost Cutting)

  • 최현주
    • 한국의료질향상학회지
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    • 제21권1호
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    • pp.52-61
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    • 2015
  • Objectives: Because recently hospital had to faced with financial hardship, we have to have more effective hospital management. The purpose of this study was to reduce loss costs of the hospital through the systematic management of medical supplies and increase operational efficiency. Methods: The team was composed of outpatient nursing staff, medical record administrator, nurses in medical insurance, medical computer center, dermatologists for this study. We surveyed for 114 people including outpatient nursing staff, nurse aids, medical assistant, physician assistant. Pre-survey period was 2013.03.11 ~ 03.30(2 weeks), and post-survey period was 2013.09.03 ~ 09.17(2 weeks). Result: We improved this way through the computational improvement, conservation campaigns, inventory management, staff training, replaced by low-cost medical supplies. The finding of this study were as follows: Comparing before and after the activity of outpatient nursing staff's degree of knowledge, performance, economic consciousness, the degree of knowledge, performance was increased, but there was no significant change in economic consciousness. Performance of Married person is higher than the unmarried, In addition, the high-position people were more the degree of knowleage, economic consciousness. After activity, correlation of goods and treatment, examinations is increasing, but statistically there was no mean. Conclusion: This study revealed that knowledge in a short period of activity, but also can improve, perform the same change in behavior is not easy. This one shows the intensive training required to sustained and systematic behavioral changes, such as changes in behavior, perform rituals to help the economy. Expensive medical supplies to replace a similar effect as the cost of materials just to have a lot of cost savings. Therefore, more medical supplies change is necessary to develop alternative treatment and cost cutting.

개인정보 보호를 위한 의료영상 발급 표준 업무절차 개발연구 (Development of Standard Process for Private Information Protection of Medical Imaging Issuance)

  • 박범진;유병규;이종석;정재호;손기경;강희두
    • 대한방사선기술학회지:방사선기술과학
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    • 제32권3호
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    • pp.335-341
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    • 2009
  • 목 적 : 기존 필름으로 발급되었던 의료영상은 IT기술의 발달로 디지털화 되어 CD로 발급되고 있다. 그러나 발급 시 신분확인을 하고 있는 의무기록과는 달리 필름을 사용하던 시절부터 의료영상은 별다른 신분확인을 하지 않는 의료기관이 많다. 이에 신청자의 개인의료정보 보호에 대한 인식 실태를 조사하고 여러 의료기관의 CD 또는 DVD 등의 매체를 통한 의료영상 복사 현황을 조사, 정보보안에 관련된 국, 내외 법률 및 권고안을 분석하여 국내 환경에 부합하는 의료영상 복사 발급과 절차를 마련하는 기준을 제시하고자 한다. 대상 및 방법 : 첫째, 2008년 5월 1일부터 7월 31일까지 수도권에 있는 33개 종합병원을 대상으로 의료영상복사 신청 시 구비서류, 발급절차 등을 전화를 통한 유선 조사를 시행하였다. 신청자에 따른 구비서류를 의료법 제 21조 2항에 의거 (1) 본인일 경우 신분증 확인, (2) 가족일 경우 신청자 신분증, 가족관계 서류(건강보험증, 가족관계증명서, 등본 등), (3) 제 3자 대리인일 경우 신분증, 위임장, 인감증명서로 기준을 마련하여 조사하였다. 둘째, 연구기간 동안 위의 기준에 따라 의료영상을 발급해 주고 있는 K 의료원에 복사를 신청하는 신청자들이 준비해온 구비서류 여부를 파악하였다. 셋째, 구비서류의 확인 및 미비 시 조치 등에 대한 발급절차의 기준을 정립하여 프로세스를 개발하였다. 결 과 : 수도권 33개 의료영상 발급현황을 조사한 결과 모든 조건을 충족한 병원은 16곳(49%), 신분증만 있으면 가능한 병원은 4곳(12%), 누구나 신청 가능한 병원 4곳(12%)이었으며 의료영상을 발급하는 부서가 아닌 진료과에서 신청하는 곳이 9곳(27%)으로 구비서류 조건여부는 알 수 없었다. 또한 신청자들이 복사 신청시 준비해온 구비서류가 조건에 충족한지 3개월간의 조사 결과 모두 준비한 경우(완비)는 629건(49%), 일부만 준비한 경우(일부 미비) 416건(33%), 모두 준비하지 않은 경우(미비) 226건(18%)이였다. 위의 연구결과를 근거로 의료영상 복사 신청 절차에 대한 프로세스를 정립하여 객관적인 응대를 할 수 있도록 하고, 환자와의 마찰을 줄이고 불편을 최소화 하면서 환자의 편의를 도모하고자 세분화된 발급절차 모형도를 작성하였다. 결 론 : 다른 전산 시스템과 달리 의료영상 시스템인 PACS가 의료기기로 분류되어 있는 것은 그만큼 의료정보의 중요성이 크다는 의미이다. 또한 의료영상의 학문적 성격으로 의학교육 및 연구에 많이 쓰이는데 이러한 이유로 쉽게 인용되고 남용 될 수 있다. 따라서 의료영상은 전문적인 교육을 받은 의료영상 관리자에 의해 적절한 발급 기준으로 발급, 관리되어야 할 것이며 이에 관한 개인정보보호와 의료영상에 대한 적극적인 홍보가 필요할 것이다.

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