• 대한예방한의학회지
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• 제18권3호
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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.

• 한국병원경영학회지
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• 제8권2호
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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.

• 한국병원경영학회지
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• 제13권1호
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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.

• 디지털산업정보학회논문지
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• 제6권3호
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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.

• 농촌의학ㆍ지역보건
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• 제31권1호
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• pp.35-46
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• 2006

명동의, 실습기록에 관한 취급과 지도실태를 파악, 검토하여 앞으로 환자실습 시에 도움이 되는 자료를 얻고자 한국과 일본의 전국간호교육기관의 성인간호학, 아동간호학 및 정신간호학을 담당하는 교수를 대상으로 우편조사를 실시한 결과, 30.9%(한국), 45.2%(일본)의 응답율을 보였다. 조사내용은 일반적 특성 4문항, 학생실습에 관한 환자 설명동의 내용으로 구성된 29문항, 교수의 실습기록에 대한 지도와 관리에 관한 15문항 및 병동의 간호기록에 대한 학생의 기록에 대한 3문항으로 총 54문항으로 구성하였다. 분석방법으로 일반적 실태는 백분율을 보았으며, 영역별로는 ${\chi}^2-test$ 및 프리드만 검정을 하였으며, 개방식질문(자유기술)에 대해서는 응답자의 내용을 카드화하고 KJ법에 기초하여 관심내용을 추출하였다. 조사결과는 다음과 같다. 간호대학생의 임상실습 시에 "환자를 정해서 실습한다"고 응답한 비율은 50.0%(한국), 99.0%(일본)였으며, 주로 "수간호사"가 환자에게 설명하였는데, 분야별로는 성인, 아동, 정신간호학의 순으로 통계적으로도 유의한 차이를 보였다. 환자의 승인을 얻는 방법으로는 "구두승인"이 대부분이었으며, 실제로 동의서를 받는 경우는 두나라 모두 없는 것으로 조사되었다. 환자배정 시 설명에서는 한국과 일본 모두 "학생이 실습으로 맡게 된다" 49.0%, 100.0%로 가장 높았고, 반대로 가장 낮은 비율은 "실습기록을 보이면서 설명한다" 7.8%(한국), "환자는 실습기록을 볼 수 있다" 0.7%(일본)로 거의 비슷한 상황이었다. 환자실습 시 설명동의에 관한 교수의견에서 일본은 "환자에 대한 설명방법의 현상", "설명동의에 관한 사고와 설명동의의 바람직한 모습", "설명동의서를 받는 것과 관련된 불안과 딜렘마", "설명동의의 도입과 교육적 기대", "설명동의에 필요한 환경", 및 "과제"의 6개로 분류되었다. 한국에서는 "환자에 대한 설명방법의 현상", "설명동의서를 받는 것과 관련된 어려움" 및 "과제"의 3개로 분류되었다. 간호대학생이 실습 시 간호기록지에 기록은 "기재한다"가 한국이 46.1%로 일본의 17.7%보다 2.6배 높게 나타났다. 환자 개인정보가 기재되고 있는 학생의 실습기록의 취급에 관한 것으로 병원 밖으로 "가지고 나간다"가 한 일 각각 50.0%, 89.7%로 유의한 차이가 있었다. 실습기록의 지도에서는 두 나라 모두 "비밀을 지킬 것을 지도하고 있다"는 것이 가장 높아 한국과 일본이 각각 92.2%, 98.3%이었으며, 가장 낮은 항목은 한국이 "실습기록에 워드프로세스를 사용하지 않도록 지도한다" 17.6% 인 반면 일본은 "실습기록에 워드프로세스를 허용하는 경우, 규칙을 정하고 있다" 6.3%로 나타났다. 학생이 병동의 간호기록지에 기재하는 것에 대한 교수의 의견을 개방식으로 질문한 결과를 범주화하여 분류한 결과, "학생이 간호기록에 기재하지 않는 것이 좋다", "과제이다", "기재하고 있다. 기재할 수 있다", "기재하는 것은 의미가 있다", "상황에 따라 판단한다", "현재는 판단하기 어렵다"의 6개 범주로 구분할 수 있었다. 결론적으로 간호대학생의 임상실습 시 환자의 설명동의는 절대적으로 필요하며 실습기록의 관리지도도 교육과 학습의 목적뿐만 아니라 환자의 개인정보의 보호라는 맥락에서 고려되어야 할 것이다. 임상현장에서는 교육적 관점에서만 해결할 수 없는 문제도 있으므로 실습기관과의 대화를 통한 실습기록과 교육의 개선을 시도할 필요가 있음을 제언한다.

• 대한간호학회지
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• 제4권1호
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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.

• 의료법학
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• 제11권2호
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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.

• 대한한의학원전학회지
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• 제31권2호
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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.

• 한국의사학회지
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• 제28권1호
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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.

• 대한한방내과학회지
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• 제41권2호
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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.