• 성인간호학회지
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• 제18권4호
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• pp.533-542
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• 2006

Purpose: The purposes of this study were to investigate medical records and to develop care records for management of patients with chest pain in the emergency department. Method: Retrospective review of the 42 medical chart of patients presented to the emergency department with chest pain were used. The collected data were analyzed with a frequency of items in the medical records. Results: In a frequency analysis of recorded items for doctors' chest pain assessment during history taking, the history/risk factors was the highest rank. The following ranks were 'commenced with when/timing, extra symptoms, place, nature, stay/radiate, alleviate/aggravate, intensity' in sequence. In a frequency of recorded items in nurse's progress notes according to nursing actions, the 'checking/monitoring' was the highest rank. The following ranks were 'performing, administering/injecting, referring/arranging, testing, preparing/catheterizing, teaching/informing' in sequence. Chest pain care records for the emergency department was designed, based upon data analysis and literature review. Conclusion: The designed records can be a rapid and effective approach tool for assessment and recording of patients with chest pain. Further research is necessary for evaluating the designed chest pain care records.

• 한국콘텐츠학회논문지
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• 제20권12호
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• pp.635-645
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• 2020

오픈노트는 환자-의사 간 온라인 진료기록 공유라고 정의할 수 있으며, 환자가 자신의 진료기록에 언제든 접근할 수 있도록 허용한 시도이다. 진료기록의 확장으로써 오픈노트 도입의 필요성을 확인하기 위해, 본 연구는 의료서비스의 일부를 담당하는 병원 종사자를 대상으로 진료기록과 오픈노트에 대한 인식과 태도를 조사하였다. 연구 결과 자신의 진료기록을 읽어보는 것은 건강상태를 이해하는데 도움이 되며, 병원 종사자들은 오픈노트의 유용성에 대체로 동의하였고 참여의향이 있는 것으로 나타났다. 한편 대상자들은 진료기록이 위·변조될 가능성이 있다고 인식하였다. 결론적으로 환자가 자신의 진료기록을 자유롭게 읽어보도록 허용함으로써 건강상태를 이해하고 자가건강관리를 향상시킬 수 있으며, 진료기록에 대한 불필요한 오해와 불신을 해소할 수도 있다. 오픈노트의 건강상의 효용성 뿐 만 아니라 의사에 대한 신뢰에 미치는 영향을 생각할 때, 실험적 검증을 위한 오픈노트 시범사업을 제언한다.

• 한국의사학회지
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• 제31권2호
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• pp.41-52
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• 2018

In this study, we research the tendency of medical text publication by examining the period of the great measles outbreak and the period of the publication of specialized smallpox texts. Using the National Institute of Korean History database for the Annals of Joseon Dynasty, the Daily Records of Royal Secretariat of Joseon Dynasty and Bibyeonsadeunglok, we will compare all records of measles occurrence. Measles and smallpox (Majin in Korean) have similar symptoms and treatment methods. In East Asia, when measles occurred it spread to Joseon and Japan, which are verified by records of the Annals of Joseon Dynasty, the Daily Records of Royal Secretariat of Joseon Dynasty and Bibyeonsadeunglok. The medical books related to measles are; Ryuhasinbang, Majinpyeon, Geupyubang, Yimsinyeokbang, Eulmisinjeon, Majingbang, Jinyeokbang, Magwahoetong, Majingibang, Susengsingam, Hongjinsinbang. Measles and Majin are the same disease. During the period of measles occurrence, measles-related medical books were published, and this relation of measles occurrence and measles-related medical text publication is verified by several national records.

• 한국의사학회지
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• 제25권1호
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• pp.11-22
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• 2012

This study is about King Kyung-jong's medical history written on "The Daily Records of Royal Secretariat of Chosun Dynasty". Kyung-jong, the 20th King of Chosun was born in 1688 as a prince and passed away in 1725. When he was prince, his main diseases were some infectious things; for example, smallpox, measles, a sort of malaria, a sort of mumps etc. But the time he was king, his main diseases were related unenergetic(虛證). According to "The Daily Records of Royal Secretariat of Chosun Dynasty" yak-bang(藥房) records, some informations about his health are different from general knowledges. At first, His father's dead is more related his health than his mother's dead. Second, he was fat, not thin(or desiccate). Third, his infertility was not caused his mother when she died. Fourth, he was regarded as one of psychological healthy person. And not exactly related Kyung-jong's health, in "The Daily Records of Royal Secretariat of Chosun Dynasty" at Kyung=jong's era, there are some meaningful informations at medical history. One is a doctor who was smallpox specialist. His name is Yoo-Sang, he treated three of Chosun's King very perfectly and his family worked for the royal family's health for 150 years, especially treating smallpox. the other is prescription Gamijojungtang(加味調中湯), Kyung-jong's favorite prescription. This prescription is considered royal special prescription at Chosun.

• 한국의료질향상학회지
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• 제5권1호
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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.

• 대한한의학원전학회지
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• 제32권2호
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• pp.49-70
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• 2019

Objectives : Medical records of Xueji in the "Xiaozhufurenliangfang" were examined in this study which aimed to look at the medical situation in gynecology of China's Ming Dynasty period, in hopes for it to yield implications and treatment directions to gynecology in $21^{st}$ century Korea. Methods : The medical records were systematically organized with a medical anthropological approach along with overall analysis of the entire records, which lent meaningful statistical information in numeric form. A bibliographical review of the text as historical artifact was undertaken as well. Results : In managing gynecological conditions, Xueji frequently attributed them to depletion of Qi and Blood of the Spleen and Liver. In terms of pathogenic factors, he frequently mentioned Fire and Heat, and as etiological factors, emotional distress. For treatment, he frequently used 'Bu Zhong Yi Qi Tang(補中益氣湯)', 'Xiao Yao San(逍遙散)' and 'Gui Pi Tang(歸脾湯)'. Conclusions : Through studying the medical records of Xueji in "Xiaozhufurenliangfang" a close look into a master's insight on gynecological disorders in terms of diagnosis and treatment was achieved. The formulas he used are widely applied even today, and this study shows that the formulas's clinical application could be expanded even wider.

• 동의신경정신과학회지
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• 제17권1호
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• pp.17-35
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• 2006

Objects : In the present study, we translated Mingyi-leian into modern Korean, and studied the medical records about the disease induced by emotional problem and the psychotherapy in Mingyi-leian for find the possibility of application that established researches did not studied. Methods : It was 197 cases that related to psychotherapy and emotional problem called Seven Passions(七情). We studied these records by statistical methods. Results : The anger(怒) was the most numerous cause into classified to Seven Passions in 197 cases. In the order of frequency of emotional causes, it was worry(憂), surprise(驚), lust(思), fear(恐), sorrow(悲), joy(喜) that classified into Seven Passions. The most disease induced by emotional problem was internal trauma(內傷), 11 cases. There was very numerous diseases induced by emotional problem except internal trauma. In ratio of the sexes, it was 104 cases in female and 93 cases in male from 197 cases. But the number of all case records about male were more than about female in Mingyi-leian, so female ratio was two times to male ratio. Specially, the percentage of cases about disease due to anger high in female. In ratio of the Seven Passions, the anger was most frequent cause of diseases due to emotional problem in 197 cases, and mostly caused bleeder's diseases. In oral medical treatments, various prescriptions were used. On the whole, the ratio of prescriptions about venting grudges(解鬱) records are mostly application of compatibility and incompatibility with the and warmly strengthening(溫補) were high. Psychotherapeutic medical Five Elements(五行) relation. But it also has psychotherapeutic medical record made by detailed and correct analysis can equal to modern psychotherapy, it is worth refer to clinic. Conclusions : Mingyi-leian and its medical records about the disease induced by emotional problem and the psychotherapeutic records have sufficient meaning to not only modern neuropsychiatric physicians but also physicians of all medical fields to treat disease of this kind.

• 한국의사학회지
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• 제33권2호
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• pp.129-145
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• 2020

This study studied the use of Woohwanggo in the Joseon royal family through The daily records of Royal secretariat of Joseon Dynasty, which contains detailed records of royal medical treatment. The study found that Woohwanggo was mainly used for diseases related to vexing heat (煩熱), fumigating heat (薰熱), night fever (夜間發熱), and heat syndrome (熱證) from smallpox, and measles in the royal family of Joseon. This study also confirmed that Woohwango was used in various ways within the Daily records of Royal secretariat of Joseon Dynasty, including the way it was taken with various types of tea, the way it was made into liquid form, and the way it was used as an external agent for skin diseases. Further findings were compared to the medical books, and the dosage characteristics of Woohwango in the daily records of Royal secretariat of Joseon Dynasty were discussed. and the medical perception of King Yeongjo (英祖), which was examined during the study, was also discussed.

• 한국의사학회지
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• 제32권2호
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• pp.91-104
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• 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.

• 디지털콘텐츠학회 논문지
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• 제11권2호
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• pp.135-144
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• 2010

의무기록은 의료행위에 대한 매우 중요한 기록으로 임의로 변경되지 말아야 한다. 현존하는 의무기록은 모두 변경될 수 있는 여지가 있다. 정보기술의 발달로 전자의무기록이 점차 널리 사용되게 되었다. 전자의무기록을 사용함에 따라 암호학적 기반을 이용하여 의무기록 변경을 방지할 수 기법을 사용할 수 있다. 본 논문에서는 연결해쉬, 전자서명, 전자공증 등의 암호학적 기법을 이용하여 의무기록 변경을 방지할 수 있는 기법을 제안하고 프로토타입을 통하여 수행을 분석한다. 제안된 기법은 적은 추가비용으로 의무기록 변경을 현실적으로 불가능하도록 한다.