• Title/Summary/Keyword: Paper-based medical record

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A Study of Comparing the Paper-Based Medical Record with the Electronic Medical Record on the Level of Medical Record Completeness and the Accordance (종이의무기록과 전자의무기록의 기재 충실도 및 일치도 비교 연구 : 의사의 입원.퇴원기록지와 간호사의 입원.퇴원간호정보기록지를 중심으로)

  • Shin, A-Mi;Jung, Sun-Ju;Lee, In-Hee;Son, Chang-Sic;Park, Hee-Joon;Kim, Yoon-Nyun;Youn, Kyung-Il
    • Korea Journal of Hospital Management
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    • v.15 no.1
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    • pp.1-12
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    • 2010
  • This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor's admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor's admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor's admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking (p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.

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Study for Improvement of the Doctor's Satisfaction and Completeness of the Medical Record in the EMR System (전자의무기록(EMR) 시스템하에서 의사의 만족도와 의무기록정보의 기재 충실도 향상 방안)

  • Park, Un-Je
    • Korea Journal of Hospital Management
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    • v.16 no.2
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    • pp.19-30
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    • 2011
  • This study aims to present ways to enhance the stabilization of electronic medical records, ensure the commitment to filling in information of the medical record and improve the overall quality Electronic Medical Record(EMR) information. For that purpose, the present state of the incomplete record rate and the doctor's satisfaction in Electronic Medical Record(EMR) have been surveyed by comparing and analyzing Paper-based Medical Record(PMR) and Electronic Medical Record(EMR). The survey was conducted on 31 doctors in charge of EMR system and each PMR and EMR inpatients were collected for a period of 5 months and analyzed. The results showed that the doctor's satisfaction level was higher for EMR, and the rate of incomplete record appeared to be lower in EMR in departments of both internal and external medicine. In this context, it can be said that the higher efficiency of EMR helped accomplish the increase in commitment to completing medical record information and improve the quality of the data.

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Personal Health Record/Electronic Medical Record Data Trading Model for Medical My Data Environments (마이데이터 환경에서 개인의 전자 건강/의료 데이터 활용을 위한 데이터 거래모델)

  • Oh, Hyeon-Taek;Yang, Jin-Hong
    • The Journal of Korea Institute of Information, Electronics, and Communication Technology
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    • v.13 no.3
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    • pp.250-261
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    • 2020
  • Today, data subjects should be considered to utilize various personal data. To support this paradigm, the concept of "My Data" has proposed and has realized in various industrial sectors, including medial sectors. Based on the concept of the medical My Data, this paper proposes a personal health record (PHR) and an electronic medical record (EMR) data trading model. Particularly, this paper proposes a system model to support the medical My Data environment and relevant procedure among stakeholders for PHR/EMR data trading that ensures the rights of data subjects. Based on the proposed system model, this paper also proposes various mathematical models to analyze the behavior of stakeholders and shows the feasibility of the proposed data trading model that satisfies the requirements of both data subjects and data consumers.

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

  • Jung, Mi-Yeong;Kim, Hye-Sook;Kim, Kyeong-Na
    • The Korean Journal of Health Service Management
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    • v.6 no.4
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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.

Blockchain-based Electronic Medical Record Sharing FrameworkUsing Ciphertext Policy Attribute-Based Cryptography for patient's anonymity (환자의 익명성이 보장되는 암호문 정책 속성중심 암호를 활용한 블록체인 기반 전자의무기록 공유 프레임워크)

  • Baek, Seungsoo
    • Convergence Security Journal
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    • v.19 no.1
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    • pp.49-60
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    • 2019
  • Medical record is part of the personal information that values the dignity and value of an individual, and can lead to serious social prejudice and disadvantage to an individual when it is breached illegally. In addition, the medical record has been highly threatened because its value is relatively high, and external threats are continuing. In this paper, we propose a medical record sharing framework that guarantees patient's privacy based on blockchain using ciphertext policy-based attribute based proxy re-encryption scheme. The proposed framework first uses the blockchain technology to ensure the integrity and transparency of medical records, and uses the stealth address to build the unlinkability between physician and patient. Besides, the ciphertext policy attribute-based proxy re-encryption scheme is used to enable fine-grained access control, and it is possible to share information in emergency situations without patient's agreement.

Design and Implementation of Electronic Medical Record System Based on HL7-CDA for the Exchange of Clinical Information (임상 정보교환을 위한 HL7-CDA 기반의 전자의무기록 시스템의 설계 및 구현)

  • Cho, Ik-Sung;Kwon, Hyeog-Soong
    • The Journal of Korean Institute of Communications and Information Sciences
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    • v.33 no.5B
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    • pp.379-385
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    • 2008
  • For the sharing and exchange of information between medical clinics, the clinical document has to be built on a standardized protocol such as a HL7-CDA. But it is difficult to exchange information between medical clinics because clinical document such as electronic medical record that include text and image, have different structure of document and type of expression. In this paper, we propose the electronic medical record system based on HL7-CDA that can share and exchange clinical information between medical institute. For this purpose, we have to design the schema of the clinical document architecture after we select the essential items of medical record and define templates. The proposed system can minimize integrating process and save parsing time when clinical information exchange and refer, by converting electronic medical record to base64 encoding scheme and integrate it in a XML document.

Improvement Plan of the Korean Electronic Medical Record (우리나라 전자의무기록의 개선방안)

  • Choi, Chan-Ho
    • Journal of Society of Preventive Korean Medicine
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    • v.18 no.3
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    • pp.11-21
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    • 2014
  • The rapid development and distribution of information communication industry facilitates the changes of hospital administration, introducing EMR(Electronic Medical Record) instead of paper-based medical record in the medical field. The developed countries such as U.S. have established EMR system after in the middle of 1970s because the primary advantages of EMR is to store and handle vast amounts of records efficiently and increase the quality of health care. Most of health organizations in Korea also apply medical record system to their administration. As the result, they have accomplished a scientific administration system through the use of medical record to handle a variety of patient's information including patient's confidentiality and privacy such as family history, social status, income level, and so on. However, access to and the misuse of EMR causes illegal infringement of patient's information and finally it becomes a very serious medical issue. Potential leakage and misuse of records may seriously infringe patient's privacy rights. In this respect, the related agencies in the public and private sector have been making efforts to prevent patient's records leakages. Especially, the revision bill of Medical Law in 2002 establishes the ways on the security and standards of electronic records. However, it does not provide the proper guidelines which is applied to the rapid changes of the medical environment. One of the most priorities in the hospital administration is the production and maintenance of an accurate medical records fulfilled by medical recorders. Therefore, it is very important for health care providers to hire ethical-based medical recorders. But, unfortunately most of hospitals overlook the importance of their roles. All parts including government, physician and patient must have more concerns on the problems related to EMR. Therefore, this study aims to propose the proper ways to resolve the problems coming from EMR.

Development of Electronic Medical Record System Using XML (XML을 이용한 전자의무기록시스템 개발)

  • Kang, Byeong-Do;Jung, Suk-Ho
    • The KIPS Transactions:PartD
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    • v.9D no.6
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    • pp.1127-1136
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    • 2002
  • In the medical field. the desire of the hospital information system based on the advanced computer technology has been increased because hospital staffs wanted to provide better medical services to their patients by using it. So, the electronic medical records have emerged to share and exchange medical and healthcare information stored in database. In this paper. we developed an electronic medical record system using XML. This system includes four modules : data repository. document structure manager, document writter and XML automatic generator. For the purpose of evaluating the usability of the electronic medical records of our system, we also applied it to out-patient medical records in the department of orthopedic surgery.

A Comparison of Efficiency between Computerized Nursing Records and the Paper-based Nursing Records - focus on patients with a stroke - (전산간호기록과 서면간호기록의 효율성에 관한 비교연구 - 급성 뇌졸중 환자의 간호기록 중심으로 -)

  • Sung Young-Hye;Cho Myung-Sook;Choi Bok-Yeon;Jang Mi-Ra
    • Journal of Korean Academy of Fundamentals of Nursing
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    • v.13 no.1
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    • pp.24-32
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    • 2006
  • Purpose: This study was a comparative review of the computerized nursing records and paper-based nursing records to examine effects of a nursing process documentation system focusing on patients who have had stroke. Method: First, the researchers collected all the foci from the computerized records and the paper-based records. They selected ten nursing foci, used frequently in both groups and analyzed the number of foci per patient, appropriateness of foci, the number of nursing activities per nursing focus and whether outcomes were described or not in the nursing record. Results: There was fewer errors in nursing diagnosis selection, and a larger number of activities in the records than trle paper based ones. Also, there was a better description of the nursing outcomes in the computerized records. Conclusion: This study suggests that the computerized nursing records is significantly effective in increasing accuracy of the nursing care plan and quality of the nursing record.

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A Study on Application of Internet-based Personal Health Record(PHR) System: Using Google Health (인터넷기반의 개인전자건강기록 시스템 적용사례 연구: 구글헬스를 중심으로)

  • Jeong, Seong-Hee
    • Journal of Digital Contents Society
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    • v.10 no.3
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    • pp.433-439
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    • 2009
  • With the help of fast growing popularization of internet, all areas of e-Health have expanded rapidly; such that people have become interested in digital personal health record and its management. This paper examined the characteristics of personal health record and made the analysis of the structure of Google Health, the internet-based personal health record system. Google Health allows you to store and manage all of your health information, import medical records from hospitals and pharmacies, share your health records, and explore online health services. This examples represents not only a significant change of current medical systems but also enables to estimate the future stream of it. As a result, this paper, in the areas of e-Health which will be expanded in various service areas, may give you a greater sense of importance of personal health record and will eventually provide more complemental structure of future personal health record through comparative studies on the strength and weakness of it.

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