• Title/Summary/Keyword: Patient's Records

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Development of an Algorithm for Emergency Nursing Care of Dyspneic Patients (호흡곤란 환자 응급간호 관리를 위한 알고리즘 개발 연구)

  • Yang, Jin-Ju;Jang, Keum-Seong
    • Journal of Korean Academy of Nursing Administration
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    • v.15 no.4
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    • pp.491-505
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    • 2009
  • Purpose: This study was to develop an algorithm for emergency nursing care of dyspneic patients. Methods: This methodological study was done through reviews of medical records and literatures, checklists of emergency nursing care for dyspneic patients, interviews with nurses, and experts' validity. Results: Firstly, the initial assessment confirmed the identification of airway patency, accessory muscle usage, RR, $SpO_2$, v/s, skin color, and mental status. Immediate emergency care provided oxygen, checked ABG, EKG, and chest X-ray, established a semi-fowler position, maintained IV routes, administered medication orders, and conducted careful monitoring. Secondly, if the patient exhibited $SpO_2$ of less than 90%, the nurse considered the patient's condition to be aggravated. Thirdly, if the patient showed improvement of more than 90% $SpO_2$, the nurse administered secondary assessment and carried out specific nursing care. However, if the patient continuously showed $SpO_2$ of less than 80%, the nurse assisted the intubation and then executed ventilator therapy. Conclusions: This study suggests that the algorithm is an effective decision tool and utilizing the algorithm is expected to improve the emergency nursing care for dyspneic patients.

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A Study on Fluid Intake and Output Measurements (수분 섭취 및 배설량의 측정방법에 관한 연구)

  • Choi, Smi;Yang, Young-Hee;Jung, Yun
    • Journal of Korean Academy of Nursing
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    • v.25 no.1
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    • pp.88-98
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    • 1995
  • The Fluid and electrolytes balance in the body is of critical importance in maintaining good health. When the fluid and electrolyte imbalance is present, patients are in great danger. They must be assessed immediately by a nurse so that appropriate treatment can be started as soon as possible. Patients' fluid intake and output records contain highly important information for the diagnosis and treatment of fluid imbalance, but, these records are often inaccurate and the method of recording the fluid intake is not universal for every hospital. Be-cause they are few quantitative measurements of a patient's hydration, the need to improve the accuracy of fluid intake records is very important. However, very few studies have been done to investigate the accuracy of measurements of patients' fluid intake and output. The purpose of this study was to investigate the methods used for calculation of fluid intake which is most similar to fluid output in normal adults and hospitalized patients. This study focused on three different calculation methods for fluid intake and compared these to fluid output and developed suggestions as to the ideal way to record fluid in-take. Data for 43 hospitalized patients and 37 normal adults were analyzed. The findings of this study are as follows ; 1) In normal adults, the daily intake of water which enteres by the oral route was 2415m1 (the first method of calculation). The daily intake of water in the form of pure water or some other beverage was 1365m1 (the third method of calculation) The daily intake of water including fresh fruits and vegetables, rice, porridges, and Me m which have water content more than 80% were 2186m1 (the second method of calculation). 2) The urine output of the normal adults was 1350m1. This apprroximates the amount of fluid an adult takes in the form of pure water. 3) In patient group, the total intake of water was 2550m1 (the first method of calculation). The in-take of water in the form of pure water or as some other beverage and IV fluid was 1661m1 (the third method of calculation). The daily in-take of water including foods which have high water content was 2356m1 (the second method of calculation). 4) The urine output of the patient's group was 1728m1. This approximates the amount of fluid an adult takes in the form of pure water. 5) Investigation of the method of calculation of the patient fluid intake showed that among the 31 hospitals studied, only eight use the third method of calculation which reflects the most close value to urine output. From the results obtained in this study, it was indicated that the amount of fluid taken in the form of pure water reflects the most close value to urine output. Therefore, it can be suggested that the third method of calculation which includes water in-take only in the form of pure water or beverage should be used as patients' fluid intake record.

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A Study about medical records in ${\ulcorner}$Gyojubuin-yangbang${\lrcorner}$ (${\ll}$교주부인양방(校注婦人良方)${\gg}$에 수재된 의무기록 의안(醫案)에 관한 연구)

  • Oh, Chang-Young;Kim, Ra-Young;Park, Young-Soo;Kim, Byoung-Hoe;Joh, Ho-Geun;Kim, Joong-Oh;Kim, Dong-Il
    • The Journal of Korean Obstetrics and Gynecology
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    • v.19 no.2
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    • pp.226-239
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    • 2006
  • Background : Medical records are documents in files which consist of all diagnostic studies and medical treatments patients had received while they were hospitalized or treated as outpatients. A doctor or medical team can use medical records as a data for diagnosis, treatment, and education. In traditional eastern asian medicine, medical reports have different forms and contents. The most important thing in medical reports of traditional eastern asian medicine was how to express practitioner's medical ideas. So it has a weak point, for example, it has poor information about patient and clinical process, which make some trouble to understand it. Methods and Results : We studied medical records in Gyojubuin-yangbang, a commentary book of Chen-zi-ming's Obstetrics and Gynecology textbook done by Xue-ji in Ming dynasty, China. This book consists of 10 parts; treatment of menstruation disorders and leukorrhea, general gynecology, treatment of infertility, education for fetus, diagnosis of fetus and gravida, treatment of general and obstetrical disease in gravida, care for delivery, postpartum care and treatment, and treatment of mass and inflammation. It has 546 medical records about women's disease that commonly believed as Xue-ji's case reports. They are all review articles and made during about 23 years from A.D 1523 to 1546. Most patients of Xue-ji's case reports were common people, this fact is different from that of case reports in Chen-zi-ming's Obstetrics and Gynecology textbook. Conclusion : Xue-ji was a very famous Ob&Gy doctor who was from Suzhou Jingsu province in China. He was born in A.D 1468, died in A.D 1588. He emphasize emotional factors in pathology and to tonify spleen and kidney. We think Xue-ji's medical records are good references for us to treat psychosomatic Ob&Gy disease and chronic women's disease.

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Identification of Cardiovascular Disease Based on Echocardiography and Electrocardiogram Data Using the Decision Tree Classification Approach

  • Tb Ai Munandar;Sumiati;Vidila Rosalina
    • International Journal of Computer Science & Network Security
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    • v.23 no.9
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    • pp.150-156
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    • 2023
  • For a doctor, diagnosing a patient's heart disease is not easy. It takes the ability and experience with high flying hours to be able to accurately diagnose the type of patient's heart disease based on the existing factors in the patient. Several studies have been carried out to develop tools to identify types of heart disease in patients. However, most only focus on the results of patient answers and lab results, the rest use only echocardiography data or electrocardiogram results. This research was conducted to test how accurate the results of the classification of heart disease by using two medical data, namely echocardiography and electrocardiogram. Three treatments were applied to the two medical data and analyzed using the decision tree approach. The first treatment was to build a classification model for types of heart disease based on echocardiography and electrocardiogram data, the second treatment only used echocardiography data and the third treatment only used electrocardiogram data. The results showed that the classification of types of heart disease in the first treatment had a higher level of accuracy than the second and third treatments. The accuracy level for the first, second and third treatment were 78.95%, 73.69% and 50%, respectively. This shows that in order to diagnose the type of patient's heart disease, it is advisable to look at the records of both the patient's medical data (echocardiography and electrocardiogram) to get an accurate level of diagnosis results that can be accounted for.

STUDY ON ANALYSIS OF SIGNIFICANCE OF SYMPTOM-TREATMENT METHOD COMBINATION

  • Oh, Yong Taek;Nam, Bo Ryeong;Kim, An Na
    • Journal of applied mathematics & informatics
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    • v.32 no.5_6
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    • pp.737-746
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    • 2014
  • Treatment method refers to a principle or method for treating diseases in Traditional Korean Medicine(TKM). As doctors determine the ideal treatment for a patient's disease or symptom, they are also able to prescribe effective treatment means for the diseases or symptom such as medicinal materials, prescription, acupuncture and moxibustion. Therefore, if significant symptom-treatment method combinations are found from literature or database, proper treatment means for the patient's diseases or symptom may be presented to TKM doctors and enhanced treatment accuracy and efficiency can be expected. This study aims to analyze the relation between symptom and treatment method by interpreting hypotheses through null hypotheses to find significant symptom-treatment method combinations. This combinations suggested in this study will be compared with TKM experts analysis result to find an objective analysis method and eventually apply the method to medical big data, e.g., a huge amount of literature or treatment records.

The development of an augmented reality prototype in dental practice management (치과의료관리 영역에서 증강현실의 프로토타입 개발)

  • Park, Seon Gyu;Lee, Jongki
    • Journal of Korean Academy of Dental Administration
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    • v.8 no.1
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    • pp.24-29
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    • 2020
  • With the advancement of information technology, the application of augmented reality (AR) in dentistry is an emerging research field of image-guided surgery and dental education. In addition, the digital approach to incorporating AR in dental practice management is considered to be feasible. A prototype is developed to apply AR to dental daily clinical practice in order to help dentists to access electronic dental records. This prototype delivers patients' information and related clinical data to dental clinicians directly without the need to search for the appropriate patients. Wearable AR devices are considered to be a convenient tool for practicing dentists because dental practitioners are not always able to use a computer during active clinical sessions, such as implant placement, root canal treatment, and patient-doctor communication. The use of AR to visualize passive transferred patient data would be valuable for practicing dentists.

Interhospital Transfer of Emergency Patients and Informed Consent (응급환자의 전원과 의사의 설명의무)

  • Bae, Hyun-A
    • The Korean Society of Law and Medicine
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    • v.13 no.1
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    • pp.249-293
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    • 2012
  • Inter-hospital transfer, depending on its medical and legal appropriateness, affect the prognosis of patients and can even lead to legal disputes. As Emergency Medical Service Act, any physician shall, in case where deemed that pertinent medical service is unavailable for such patient with the capacities of the relevant medical institution, transfer without delay such patient to another medical institution where a pertinent medical service is available. For medico-legally appropriate inter-hospital transfer, the head of a medical institution shall, in case where he transfers an emergency patient provide medical instruments and manpower required for a safe transfer of the emergency patient, and furnish the medical records necessary for a medical examination at the medical institution in receipt of such patient. And transfer process must comply with the requirements prescribed by executive rule such as attachment of the referral, provision of ambulance, fellow riders and informed consent of transfer. Those engaged in emergency medical service shall explain an emergency medical service to an emergency patient and secure his consent. In addition to the duty to inform about emergency medical service to the patient and his or her legally representative, there is also a duty for doctors to sufficiently explain to the patient and his or her legally representative during inter-hospital transfer that the need for the transfer, the medical conditions of the patient to be transferred and emergency treatment that will be provided by the hospital from which the patient is going to transferred. Likewise, the hospital to which the patient is transferred must be thoroughly informed about matters such as the patient's conditions, the treatment the patient was given and reasons for transfer by transferring doctors.

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The Effect of the Patient's Characteristics on Nursing Outcomes in Gastrointestinal Surgery Patients (간호결과에 대한 환자 특성의 영향 - 위장관계 수술 환자를 중심으로 -)

  • Lee, Byoung-Sook
    • Journal of Korean Academy of Nursing Administration
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    • v.14 no.3
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    • pp.249-259
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    • 2008
  • Purpose: This study was performed to identify the patient characteristics significantly affecting nursing outcomes and their predictability in gastrointestinal surgery patients. Method: The subjects were 149 abdominal surgery patients from 3 general surgical nursing units of 3 general hospitals. Two instruments were used to measure nursing outcomes and acuity of the subjects. The nursing outcomes were measured at post-operation 4 and 7days using review of patients' records, observation of patients, and interviews with patients by a trained nurse. For data analysis, T-test or ANOVA, Pearson Correlation and Stepwise Multiple Regression were done. Result: Age, severity score, diagnosis, cancer or not, operation site were the subjects' characteristics that were significantly related to the nursing outcomes in both post-operation 4 and 7days. Cancer or not, age, diagnosis and severity score were the significant predictors for the scores of nursing outcome in post-operation 4days and the predictability was 34.9%. The predictability of cancer or not was highest, 22.6%. Age, diagnosis and cancer or not were the significant predictors for the scores of nursing outcome in post-operation 7days and the predictability was 27.8%. The predictability of age was highest, 17.3%. Conclusions: The patient characteristics affecting nursing outcomes should be considered when nursing care is planned and provided. Especially, careful attention should be given to the patients with cancer and older age. And, these patient characteristics should be adjusted for correct estimation of the effectiveness of nursing interventions on nursing outcomes.

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Factors influencing the appropriateness of hospital stays (재원 적절성에 영향을 미치는 요인)

  • Hwang, Jee In
    • Health Policy and Management
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    • v.15 no.3
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    • pp.94-113
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    • 2005
  • The purpose of this study was to determine the level of appropriateness in hospital stays and factors influencing inappropriate hospital stays. The study was conducted at fifteen general care units in a tertiary university hospital. Appropriateness of hospital stay was assessed using Appropriateness Evaluation Protocol by trained head nurses. The total of 447 patient records were reviewed. Among them, 352 patient data were included in the final data set. A unit of observation was patient day. A rate of appropriate hospital stay was calculated per patient as a unit of analysis. Multiple regression analysis was performed to determine the factors affecting inappropriate hospital stay. The eighty-three percent (2030/2651) of hospital stays were evaluated as appropriate. There were significant differences in appropriateness of hospital stay according to patient's age, type of health insurance, medical specialty, and length of stay(p<0.05). In the multiple regression analysis, medical speciality was the most significant factor to predict the inappropriate hospital stay. The study showed a substantial proportion of hospital stay was found to inappropriate. Level of appropriateness was significantly different from medical specialty. Interdepartmental approach should be required to coordinate and improve appropriate resource utilization.

A case study of a patient with atopic dermatitis who improved with Shanghanlun Hoeyeok-tang (『상한론(傷寒論)』 회역탕(回逆湯)으로 호전된 아토피피부염 환자 1례에 대한 증례 연구)

  • Eunkyo Lim;Hyun-yee Ha;Il-Woong Jang;Soong-in Lee
    • Herbal Formula Science
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    • v.31 no.2
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    • pp.125-132
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    • 2023
  • Objective : The objective of this study is to report a case of atopic dermatitis (AD) treated with Hoeyeok-tang. Methods : We retrospectively reviewed the course of herbal medicine treatment in a 20-year-old male patient with a topic dermatitis. Changes in main symptoms were confirmed based on the gross findings and assessed using SCORing Atopic Dermatitis(SCORAD) Index. Accompanying symptoms and side effects that can be referred to for diagnosis were analyzed By referring to the clinical records. Results : According to the Shanghanlun provision, the patient's AD was diagnosed with Terminal-yin Gwakran 389th provision. The patient was treated with Hoeyeok-tang for 90 days. The severity of pruritus decreased, and SCORAD Index was decreased from 44.6 to 8.4. VAS for eye fatigue and nausea was decreased from 10 to 5, also. No particular side effects occurred to the patient while taking the Hoeyeok-tang. Conclusions : The result suggests the clinical applicability of 389th provision of Shanghanlun.