• Korean Journal of Adult Nursing
• /
• v.18 no.4
• /
• pp.533-542
• /
• 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.

• The Journal of the Korea Contents Association
• /
• v.20 no.12
• /
• pp.635-645
• /
• 2020

An "OpenNote" can be defined as the sharing of medical records between patient and doctors by online, and is a new trial to allow patients to access their medical records any time. To identify the need for the introduction of OpenNotes, which is expanding medical recrods, this study has researched the awareness and attitude towards medical records and OpenNotes among hospital workers in charge of part of medical servises. One of the results in this study is that recognizing his or her own records can impact his or her understanding his or her health status. Also, the subjects who were participated in this study generally agreed with the usefulness of the OpenNote and were willing to participate in the OpenNote. Meanwhile the subjects are admitting counterfeiting the medical records or falsifying them. The conclusion has been shown that patient-doctor sharing of medical records could help patients better understand their health information and encourage their self-care. When patients can access their own medical records easily, Unnecessary misunderstandings and distrust of records between patients and medical staff can be markedly reduced then it can help to build up the trust in a doctor-patient relationship. Considering not only the health utility of OpenNotes but also the impact on the trust of doctors, the pilot project of OpneNotes for experimental verification is proposed.

• The Journal of Korean Medical History
• /
• v.31 no.2
• /
• pp.41-52
• /
• 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.

• The Journal of Korean Medical History
• /
• v.25 no.1
• /
• pp.11-22
• /
• 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.

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

• Journal of Korean Medical classics
• /
• v.32 no.2
• /
• pp.49-70
• /
• 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.

• Journal of Oriental Neuropsychiatry
• /
• v.17 no.1
• /
• pp.17-35
• /
• 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.

• The Journal of Korean Medical History
• /
• v.33 no.2
• /
• pp.129-145
• /
• 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.

• The Journal of Korean Medical History
• /
• v.32 no.2
• /
• pp.91-104
• /
• 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.

• Journal of Digital Contents Society
• /
• v.11 no.2
• /
• pp.135-144
• /
• 2010

Medical records are very important records and should not be modified after creation. The current medical records are liable to improper modification. With the development of information technology, electronic medical records (EMR) are used widely. For the EMR, cryptographic primitives may be used to develop techniques to prevent medical record modofication. In this research, a technique to prevent improper medical record prevention is proposed. It uses crytographic primitives such as linked hash, digital signature, and electronic notarization. A prototype system is also developed for performance analysis. The proposed method makes the medical record modification impossible with a small amount of additional cost.