• 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.

• Korea Journal of Hospital Management
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• v.8 no.2
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• pp.111-129
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• 2003

This study discusses the direction of legislation to strengthen the legal protection of medical records privacy in information age. The legislation trends on privacy protection of medical records in European Union and United States are analysed and the current law and regulation of Korea on medical records are compared. The issues discussed include the ownership of medical records, the patient's right of access to medical records, medical information publication for other than treatment or insurance processing use, confidentiality responsibility of provider organizations, medical information management in provider organizations, penalty for the unlawful use of patient information. This study concludes that the patients' right on medical record and provider organization's responsibility in processing patient information should be strengthened in order to protect patients' privacy and to conform to the international standard on medical record protection in the information age.

• Korea Journal of Hospital Management
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• v.13 no.1
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• pp.42-64
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• 2008

This study was conducted to evaluate the quality in medical records by analyzing its completeness through setting up the level of record on the patient's past history and through examining the actual medial records. Targeting the information on the patient's past history in interns' records, residents' records and nurses' records toward 403 inpatients who were admitted first in 2004 at an university hospital due to stomach cancer. We analyzed whether the charts were recorded or not, recording level, the satisfaction with the expectant level of the records in the hospital targeted for a research and the level of agreement. The results were as follows; first, as for the rate of recording those each items, they were high in the chief complaint & present illness and the past illness history. Depending on the group of recorders, the recording rate showed big difference by items. Second, as a result of measuring the level after dividing the recording level of items for the patient's past history from Level 1 to Level 4 by each item, the admission history, the past illness history, and the family history were about Level 3, and the smoking history, the medication history, the chief complaint & present illness, the drinking history and allergy were about Level 2. In the admission department, it was excellent in the interns' records for the medical department. Third, as a result of its satisfactory level by comparing the expect level of a record and the actual record by item in information on the patient's past history, which was expected by the medical-record committee members of the hospital targeted for a study. And forth, we analyzed the level of agreement with Kappa score in the level of 'Yes' or 'None' related to the corresponding matter in Level 1, in terms of information on the past history in the intern's record, the resident's record, and the nurse's record. The level of agreement in the resident's record & the nurse's record, and in the intern's record & the resident's record was from "excellent" to "a little good". There were differences in the level of completeness and in reliability for the information on the past history by the recorder group or by the admission department. The encounter process that was performed by the admission department or the recorder group, indicated the result that was directly reflected on the quality of medical records, thus it was required further study about the medical record documentation process and quality of care. The items that showed the high recording rate quantitatively were rather low, consequently we'd should develop the tool for the qualitative inspection and evaluate the medical records further. And the items were needed to be detailed in the record level were rather low, and hence there needed to be a documentation guideline and education by the clinical departments.

• Journal of Korea Society of Digital Industry and Information Management
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• v.6 no.3
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• pp.91-101
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• 2010

By using the U-Healthcare environment, it is possible to receive the health care services anywhere anytime. However, since the user's personal information can be easily exposed in the U-Healthcare environment, it is necessary to strengthen the security system. This thesis proposes the technique which can be used to protect the personal medical records at hospital safely, in order to avoid the exposure of the user's personal information which can occur due to the frequent usage of the electronic chart according to the computerization process of medical records. In the proposed system, the following two strategies are used: i) In order to reduce the amount of the system load, it is necessary to apply the partial encryption process for electronic charts. ii) Regarding the user's authentication process for each patient, the authentication number for each electronic chart, which is in the encrypted form, is transmitted through the patient's mobile device by the National Health Insurance Corporation, when the patient register his or her application at hospital. Regarding the modern health care services, it is important to protect the user's personal information. The proposed technique will be an important method of protecting the user's information.

• Journal of agricultural medicine and community health
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• v.31 no.1
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• pp.35-46
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• 2006

Objectives: In recently. the management and protection on individual information in patient's medical & nursing records have been very important, and that need a guideline. The purpose of this study was to investigate the status of using the patient's nursing records of nursing students in clinical practice, to find and discuss the patient's informed consent, and status of education and management concerned to patient's nursing records. Methods: This study used a mailing survey. data collected from September 24th to October 31th in 2002. The subject were 333 professors who are major in adult nursing, pediatric nursing, psychological nursing of 111 university of nursing department and nursing college. And then we received the survey mail from 103 professors that respondent rate was 30.9%. Results: The characteristics of study subjects showed 49.0% of university. 51.0% of college of nursing. 50.0% of the subjects practiced point the patient by oral approval in clinical practice. But when the decision of the patient was very difficult, 21.6% of the subjects take to informed consent from his or her families. During the clinical practice, 49.0% of the subjects were explain to patient about clinical practice and contents of the nursing student, only 7.8% of the subjects were explain to patient with nursing records. 52.0% of the subjects were took out records from the hospital, only 17.6% of the subjects had standard of the patient's informed consent and standard of handling practice records. 17.6%-92.2% of the subjects that educate and manage concern to patient's nursing records.

• Journal of Korean Academy of Nursing
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• v.4 no.1
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• pp.22-37
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• 1974

Through the examination of hospitalized patient's records, this study purports to determine. the extent to which nursing record behaviors meet general expectations held for nursing records and the differences in nursing record behavior in relation to different nursing categories, period of recording and hospitals with different management patterns. Nursing record behaviors of 802 patient's records in four hospitals in Seoul were examined. by use of a check list, which was prepared by the author as an instrument for the study. Data obtained from this examination were processed into percentage values for percentage. test and chi-square test in order to determine their significance. Results are as follows; 1. Records pertaining to treatment ranked highest among all care categories in their extent of coverage, averaging 65.6 percent. 2. Of the treatment category records, records of medication led others at 94.3 percent. followed by records of test and collection of specimens at 59.9 percent. diet at 58.8 percent and treatment at 41.0 percent. 3. Records in the category of physical assessment and care averaged 44.1 percent, the second highest next to treatment category records, 4. Of the records in the category of physical assessment and care, records in vital signs. placed first at 98.9 percent, followed by sleep at 76.2 percent, body weight at 74.7 percent, symptoms and signs at 69.3 percent, rest at 44.5 percent, hygiene at 39.7 percent, activities and participation at 16.9 percent, positions at 10.3 percent, level of consciousness at 9.8 percent and physiological dysfunction at 1.1 percent in that order. 5. Records in the category of psychological assessment and care averaged 3.2 percent, the lowest of the -three major categories. 6. Of the records in the category of psychological assessment and care, records on emotional responses ranked top at 10.5 percent, followed by self-concern at 2.1 percent, adjustment at 2.0 percent, family, occupational and social relations at 0.7 percent and preferences. and interest at 0.5 percent in that order. 7. Records in relation to the category of specific conditions were found in 9.1 percent of the total records. 8. Of the records in the category of specific conditions, consultation and transfer records, stood first at 25.0 percent, followed by precautionary measurements at 1.4 percent and isolation at 0.9 percent 9. A great difference in nursing record behavior was observed between the first week of hospitalization and the last week, with the first week's recordings much higher than the last week in the categories of treatment and specific conditions (p<0.01). and of physical assessment and care (p <0.05). 10. A big difference was also observed among the hospitals (p<0.01). 11. A big difference was also observed between the government-run hospitals and the private hospitals in the categories of physical assessment and care and specific conditions in the first week of hospitalization (P<0.05l), and in the category of psychological assessment and care in the last week (P<0.05). 12. Between the hospitals established with foreign aid and the other hospitals, the difference in nursing record behavior was significant only in the category of physical assessment and care both in the first week and the last week (P<0.01). 13. The average nursing record behavior in all care categories stood at 45.1 percent in the extent of its coverage in relation to the general expectations.

• The Korean Society of Law and Medicine
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• v.11 no.2
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• pp.309-335
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• 2010

This study is a paper reviewed legal status of medical personnel and issues of law on recently discovered medical records. As the increase of medical personnel who have gone through the administrative disposal in regards to the medical records, it is needed to examine the legal issue or dispute on the medical records under the current law. Medical records are the statement on patient's medical conditions made by the medical personnel. This records are used as important source for patient's further treatment. This becomes the communication route between the patients and the other medical personnel, and it provides the patients a right to find out their medical information. According to the Medical Service Act (Article 21), a medical personnel shall prepare respectively a record book of medical examination and treatment. And medical personnel shall make a signature. Furthermore, the medical personnel or the opener of the medical institutions must preserve the record book (including an electronic medical record). Meanwhile, the issues of a ban on false entry, additional record, revision or manipulation on the medical record have been recently on the rise. This paper briefly examined the major issues in regards to the medical records. It especially clarified the legal duty on medical records and its major-contentious-issues. At the same time, it pointed out the problems of the unreasonable over interpretation of the law. Furthermore, this suggested the guidelines for the further discussion and review.

• Journal of Korean Medical classics
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• v.31 no.2
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• pp.105-126
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• 2018

Objectives : This paper aims to study the educational meaning of Shanghanjiushilun in Shanghanlun education focusing on purgation therapy. Methods : Clinical medical records in Shanghanjiushilun associated with purgation therapy were chosen, analyzed and its educational meaning was studied. Results & Conclusions : 1. Xushuwei's clinical medical records are significant as it helps the readers think of various disease mechanisms by not omitting mistreatment of the other doctors. 2. Xushuwei's clinical medical records are significant as it helps the readers become aware of the importance of a differential diagnosis through questions and answers. 3. Xushuwei's clinical medical records are significant as it helps the readers avoid looking at one side of things through taking a comprehensive look at disease syndrome in various fields. 4. Xushuwei's clinical medical records are significant as it helps the readers escape unreasonableness by suggesting practical aspect managing the patient. 5. Xushuwei's clinical medical records are significant as it enable the readers to draw a new disease mechanism interpretation by making up for explanations of the pathogenesis quoting medical classics. 6. Consequently, in learning and teaching Shanghanlun, Xushuwei's clinical medical records have enough educational meaning as mentioned above.

• The Journal of Korean Medical History
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• v.28 no.1
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• pp.143-158
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• 2015

The purpose of this study is to examine the prescription of Geoseohwajung-tang which often appears in Kim Yeoung-hun's medical records and how he employed this prescription. Geoseohwajung-tang is a prescription that can be found in no books of medicine in East Asia other than Kim Yeoung-hun's medical records, his posthumous work, Cheongganguigam, and Seungjeongwon Ilki, the diaries of royal secretariat of the Joseon dynasty. It was mostly used for digestive problems resulted from eating wrong food in summer and diversely applied by changing the composition of the medicinal ingredients according to the patient's symptoms. To see how Geoseohwajung-tang was used clinically, the researcher analyzed Kim Yeoung-hun's medical records written in 1915~1924. Among his total 21,369 medical records, 549 ones included Geoseohwajung-tang, and all of them were in July to September, so we can see that it was a prescription for the summer season. The use of the prescription was not highly related with the patient's gender, occupation, or age. The names of the diseases are mostly diarrhea, dysentery, acute vomiting with diarrhea, and all of them are highly related with diarrhea. The causes of them are mostly summer-heat, dampness, and food poison.

• The Journal of Internal Korean Medicine
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• v.41 no.2
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• pp.150-158
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• 2020

Objectives: This study aimed to investigate the effect of Soeumin-Seonghyangjeongki-san on diarrhea with tube feeding causing mental deterioration induced by subdural hemorrhage (SDH) in an 83-year-old male patient. Methods: The patient was treated with Soeumin-Seonghyangjeongki-san. His symptoms were assessed using the Bristol stool form index, the King's Stool Chart, and records of stool state. The treatment was executed for one week from September 10, 2018 to September 16, 2018. The patient was observed during that same period. Results: After being treated with Soeumin-Seonghyangjeongki-san for seven days, the patient's diarrhea symptoms were evaluated using the Bristol stool form index, the King's Stool Chart, and records of stool state. After the treatment, the results of all three evaluation methods showed that the patient's condition had improved. Conclusions: The results suggest that Soeumin-Seonghyangjeongki-san can be a valuable option for treating diarrhea with tube feeding causing mental deterioration induced by SDH.