• Title/Summary/Keyword: Medical Record Analysis

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Analysis of Standard Nursing Statements Recorded in an Electronic Nursing Record System and User Satisfaction (전자간호기록에 사용된 표준간호진술문 활용실태와 시스템 사용자 만족도)

  • Jung, Joo Hee;Myung, Geun Hee;Kang, Kyung Hyun;Park, Eun Hee
    • Perspectives in Nursing Science
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    • v.9 no.2
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    • pp.146-153
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    • 2012
  • Purpose: The aims of this study were to analyze the frequency of standard nursing statements used in the Electronic Nursing Record (ENR) and to evaluate the degree of satisfaction by users of the ENR system. Methods: We retrospectively reviewed the ENR of 1914 patients who were admitted to our center between 1 May 2011 and 31 May 2011. Additionally, we collected questionnaires from 100 doctors and 300 nurses to evaluate the satisfaction of the users. Results: The frequency of use for the following standard nursing statements was investigated: standard nursing assessment statements (43.6%), standard nursing diagnosis statements (61.8%), standard nursing plan statements (46.7%), standard nursing intervention statements (56.9%), and standard nursing evaluation statements (41.7%). The mean satisfaction score was 3.03 out of 5 in the nurse's group, and 3.11 in the doctor's group. The nurses said the advantages of the ENR system were as follows: easy to access, informative, and standardized terms. However 75.7% of the nurse answered that they cannot express actual nursing situations exactly with the currently limited standard nursing statements. Conclusion: Development of various standard nursing statements is needed to meet the demands of the users. As a result, the use of the ENR system would become easier and more efficient for its users.

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A Study on the Author and Writing Year of the Marjinpyeon (마진편(麻疹篇) 저자와 저술 시기에 대한 고찰)

  • Yoo, Chul-Ho;Kim, Nam-Il
    • The Journal of Korean Medical History
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    • v.25 no.2
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    • pp.137-153
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    • 2012
  • A thesis insisting that Sugjong's medical doctor Yoo Itae(劉以泰) and the author of Marjinpyeon Yoo Itae(劉爾泰) are not a same person and his activities were in Heonjong(헌종) period, and his writing Marjinpyeon is in 1846, is published. In this study, I'd like to reveal that Yoo Itae(劉爾泰), the Marjinpyeon's author and Yoo Itae(劉以泰), Sugjong's medical doctor are a same person through analysis of Geochang Yoo's genealogy, articles, The True Record of the Joseon Dynasty, Seungjeonilgi, Taeweonseonsaengan, Sancheong-gun's paper, Sancheong Hyanggyo's paper, Sancheong-gun's paper, The geographic paper, Dongyuhagan, Sawoo Munjib, and analysis of folk story, the wrote year of his Marjinpyeon and Inseomunkyunrok and his birth year. According to my analysis, Yoo Itae(劉爾泰), the Marjinpyeon's author and Yoo Itae(劉以泰), Sugjong's medical doctor are a same person. And Marjinpyeon is written in 1696, the year of Byongja, and other his books, InseoMungyonlok at 1709, the year of Gichug. In conclusion, Yoo Itae(劉以泰.劉爾泰) was a famous medical doctor at Sancheong, born in 1652 (HyoJong the $3^{rd}$ year) and passed in 1715 (SugJong the 41th year), left books of Marjinpyeon, Silheomdanbang, and Inseomunkyunrok.

Trends and Characteristics of Patients Who Have Been Received the Physical Therapy of Korean Medicine at an University Hospital: A Retrospective Medical Chart Review (일개 대학병원 내 한방물리요법을 받은 환자들의 후향적 의무기록 분석)

  • Hwang, Eui-Hyoung;Lee, Hyeon-Yeop;Heo, Kwang-Ho;Cho, Hyun-Woo;Hwang, Man-Seok;Shin, Mi-Suk;Kim, Jeong-Hwa;Park, Seong-Ha;Shin, Byung-Cheul
    • Journal of Korean Medicine Rehabilitation
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    • v.24 no.1
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    • pp.55-63
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    • 2014
  • Objectives The aim of this study was to offer the fundamental data for the physical therapies of Korean medicine through analyse the database of one university hospital. Methods As this study was retrospective analysis, following items were selected and analysed in the electronic medical record (EMR) database. (1) sex, (2) inpatient or outpatient, (3) medical department, (4) diagnosis, (5) kind of insurance. Results Although all kind of physical therapies were used, interferential current therapy (ICT) was the most used physical therapy. And department of rehabilitation medicine of Korean medicine prescribed physical therapies most among the 8 specialty departments. As physical therapies were used in various kinds of diseases, they were especially used in musculoskeletal diseases and nervous system diseases. Conclusions The analysis of actual condition of using physical therapies in a real clinical setting of Korean medicine could be a useful fundamental data for the application of modernized physical therapies.

Knowledge Based Recommender System for Disease Diagnostic and Treatment Using Adaptive Fuzzy-Blocks

  • Navin K.;Mukesh Krishnan M. B.
    • KSII Transactions on Internet and Information Systems (TIIS)
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    • v.18 no.2
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    • pp.284-310
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    • 2024
  • Identifying clinical pathways for disease diagnosis and treatment process recommendations are seriously decision-intensive tasks for health care practitioners. It requires them to rely on their expertise and experience to analyze various categories of health parameters from a health record to arrive at a decision in order to provide an accurate diagnosis and treatment recommendations to the end user (patient). Technological adaptation in the area of medical diagnosis using AI is dispensable; using expert systems to assist health care practitioners in decision-making is becoming increasingly popular. Our work architects a novel knowledge-based recommender system model, an expert system that can bring adaptability and transparency in usage, provide in-depth analysis of a patient's medical record, and prescribe diagnostic results and treatment process recommendations to them. The proposed system uses a set of parallel discrete fuzzy rule-based classifier systems, with each of them providing recommended sub-outcomes of discrete medical conditions. A novel knowledge-based combiner unit extracts significant relationships between the sub-outcomes of discrete fuzzy rule-based classifier systems to provide holistic outcomes and solutions for clinical decision support. The work establishes a model to address disease diagnosis and treatment recommendations for primary lung disease issues. In this paper, we provide some samples to demonstrate the usage of the system, and the results from the system show excellent correlation with expert assessments.

Nursing Knowledge/Power and Practice in Pediatric Intensive Care Unit (간호학적 지식/권력과 실무: 아동중환자실을 중심으로)

  • Lee Eun Joo;Hong Kyung Ja
    • Child Health Nursing Research
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    • v.7 no.1
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    • pp.85-95
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    • 2001
  • The purpose of this study was to reveal what influences the divergent methodological researches have brought the nursing practice in during the past 3 decades. The nursing record sheets ie, the nursing discourses were analyzed to know the knowledges that were recorded, accepted and communicated in nursing practice at pediatric intensive care units, and unclosed the philosophical and methodological position of that knowledges. The texts were 13 sheets, 3 kinds of nursing record(7 24hours flow charts, 4 nursing information record sheets and 2 transfer record sheets) used at 4 hospitals. The unit of analysis was 'word'. First, all words of the sheets were listed up, clustered into categories based on their contents. And then, the larger conceptual themes were drawn to elucidate the effect of the knowledge/power and the philosophical and methodological position of that knowledges. To enhanced the validity of the analysis, the data were analyzed by two researchers. The 'words' were classified into 3 categories; 'general information', 'assessment' and 'inter-vention'. The conceptual themes of the texts were 'the gaze for quantification and objectification' and 'technical/assimilated caring'. This themes reflected the logic positivistic and biomedical view that had dominated at clinical practice. Nursing has endeavored to resist the logic-positivistic knowledge/power and to established the nursing knowledge/power based on multiple philosophies and methodologies, especially phenomenological-interpretative. But the results of this study revealed that such efforts in nursing theory and research couldn't influenced the knowledge of practice. Logic positivism was yet so strong and the biomedical model yet dominated in the clinical practice. It identified that the borrowed theory and the knowledge from the received view gave nursing the power. But they were modalities that reinforced the dominant, medical power. Nursing has investigate the other positions (feminism, Habermas' critical social theory and Foucault's discourse theory). This positions suggest different assumptions but share the common concepts; equality, emancipation and freedom. The important point is how make these concepts the practical for nursing knowledge/power in practice. We must recognize that the praxis at clinical setting take place at the field unlike theoretical praxis. The change of clinical practice is the social, economic and political change.

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Development of a Medical Information on Processing, Analysis and Management System (의료정보의 처리, 분석, 관리 시스템 개발)

  • Kim, Hie-Sik;Kim, Gyu-Sik;Choi, Gi-Sang
    • Proceedings of the KOSOMBE Conference
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    • v.1997 no.05
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    • pp.195-198
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    • 1997
  • A medical information management system for small to medium sized clinics and hospitals is developed. The system is designed to process, analyze and manage each patient's clinical record using database technique. The structure of the database was determined and implemented through careful and rigorous study of medical practices in Korea and, therefore, reflects the needs of information management in Korean medical community. Furthermore, a sophisticated inference engine that can deduce possible diseases from the result of medical examination is added to the system to provide doctors with a guideline in medical diagnoses.

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Exploring the Ways to Apply Korean Traditional Medical Practices to the International Classification of Health Interventions through Focus Group Discussion (초점집단토론을 통한 국제의료행위분류의 한의의료행위 적용 방안 연구)

  • Kim, Mikyung;Kim, Eun-Jin;Cho, Yun-Jung;Han, Chang-ho
    • The Journal of Korean Medicine
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    • v.41 no.3
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    • pp.125-137
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    • 2020
  • Objectives: This study was aimed to present the experts' opinions for the successful application of Korean traditional medical practices (KTMPs) to the International Classification of Health Intervention (ICHI). Methods: Two doctors of Korean Medicine and two health information managers who had tried coding 131 KTMPs using ICHI participated in the focus group discussion. The remarks from the discussion were summarized according to the thematic analysis method. Results: The participants expected ICHI to be mainly used for statistics when applied to TKMPs. It can be used for payment systems as well, but it was expected that additional work would be required. They thought the current version of the ICHI did not sufficiently reflect the KMTPs of the real world, and even the interventions already included in the ICHI were not explained enough in the system. They thought it would not be easy to explain more KTMPs within the current structure of the ICHI, but they also said it seemed possible. In the process, rather than adding entirely new stem codes, it would be better to generate new combinations of the existing codes, to suppose subdivided codes, and to utilize the include terms or extension codes. Conclusions: For the successful introduction of ICHI, clarifying the definition of each intervention of KTMPs is a top priority. In addition, it is necessary to continue the matching work of ICHI - KMPTs and also required to make this effort together with the field of traditional medicine and complementary medicine worldwide.

488 cases analysis of tongue characteristic from case record monographs of Warm disease in Qing Dynasty (488례청대온병의안적설상분석)

  • Li, Ya;Wang, Shenghua;Hou, Yangfang;Guan, Junda;Liang, Rong
    • Journal of Korean Medical classics
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    • v.19 no.3
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    • pp.427-431
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    • 2006
  • From 51 monographs of case record in Qing Dynasty, we chose 29 monographs in which tongue diagnosis applied to Warm disease. Then extracted all the case records and got 488 cases from them. In according to the classification of tongue diagnosis in teaching material of TCM diagnosis of higher TCM schools education, we had a statistic analysis on the 488 cases. Results show that the recording rate of tongue coating was highest, 65.16%. From high to low sequentially, the frequency of different fur was yellow fur, white fur and black fur. During $1850{\sim}1911$ of Qing Dynasty, the description of tongue coating changed that the proportion of white fur, yellow fur and compound fur was increased. On the contrary, the proportion of black fur was decreased. The recording rate of the color of tongue was 23.16%, in which the rate of red tongue and crimson tongue were higher. The recording rate of fur character was 37.7%. During $1850{\sim}1911$ of Qing Dynasty, the recording rate of greasy fur was increased to the first. The application of tongue diagnosis involves the warm-heat species of Warm Disease, damp-heat species of Warm Disease and pestilence.

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Factors related to empowerment of paramedic students who experienced clinical practice (임상실습을 경험한 응급구조(학)과 학생의 임파워먼트 관련 요인)

  • Song, Seo-Yeong;Han, Mi-Ah
    • The Korean Journal of Emergency Medical Services
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    • v.20 no.1
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    • pp.17-30
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    • 2016
  • Purpose: This study investigated factors related to empowerment of paramedic students. Methods: A total of 208 students in the department of emergency medical services who experienced clinical practice at 5 universities were selected by convenience sampling methods. Differences in empowerment by general and major-related characteristics were evaluated using a t-test and analysis of variance. The association between satisfaction with clinical practice and empowerment was tested using correlation coefficients. Multiple linear regression analysis was performed to investigate the factors associated with empowerment. Results: The levels of overall satisfaction with clinical practice and empowerment were 107.48 and 99.46, respectively. In simple analysis, empowerment level was associated with general characteristics, major-related characteristics, characteristics of clinical practice, and satisfaction with clinical practice. Empowerment level was significantly higher in older subjects (${\beta}=5.282$, p = .023), subjects with very good (${\beta}=8.487$, p = .002) or fair (${\beta}=4.879$, p = .010) subjective health status, and high subjective school record (${\beta}=5.837$, p = .008) in multiple linear regression analysis. Satisfaction with clinical practice was positively associated with empowerment (${\beta}=0.250$, p < .001). Conclusion: Empowerment was associated with major-related factors and satisfaction with clinical practice. Increased satisfaction with clinical practice could positively influence empowerment for paramedic students.

An analysis of nursing focuses for standardization of ICU nursing records (중환자실 간호기록 표준화를 위한 간호초점 분석)

  • Kang, Young-Mi;Yu, Ji-Ho;Cho, Yong-Ae;Ryoo, Sung-Suk;Cho, Jeong-Koo;Sung, Young-Hee
    • Journal of Korean Critical Care Nursing
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    • v.1 no.1
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    • pp.73-83
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    • 2008
  • Purpose: Purpose of this study was to analyze the nursing focuses for standardization of ICU nursing records. Methods: The data were collected from 1,000days'nursing records of 197 ICU patients at a tertiary hospital in Seoul. Nursing focuses were unified at the consulting group meeting and they were cross-mapped with the NANDA nursing diagnoses. Results: The 62 nursing focuses in 7 NANDA categories were extracted from nursing record. Among total nursing focuses 41 correspond to the NANDA nursing diagnoses and 21 were added to ICU nursing focuses. The 10 most frequently used nursing focuses are 'Ineffective airway clearance', 'Impaired gas exchange', 'Ineffective tissue perfusion: cardiopulmonary', 'Ineffective breathing pattern', 'Ineffective tissue perfusion: renal', 'Ineffective infant feeding pattern', 'Risk for impaired skin integrity', 'Hyperthermia', 'Impaired skin integrity', 'Decreased cardiac output', Conclusion: Nursing focuses list of ICU was extracted from the result of this study. These nursing focuses might form a framework for development of research-based assessment guideline and care plans for ICU patients through standardization of nursing records.

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