• Title/Summary/Keyword: Records Contents

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Development of Documentation System in Hospital-based Home Health - in one general hospital in the U.S.A. - (병원중심 가정간호 기관의 기록체계개발 - 미국 일개 종합병원을 대상으로 -)

  • Kang Chang-Hee
    • Journal of Korean Public Health Nursing
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    • v.6 no.2
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    • pp.58-69
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    • 1992
  • The purposes of this study were 1) to assess the currunt documentation system 2) to identify the problems in communication regarding to documentation 3) to develop new documentation system 4) to suggest effective communication channel using new documentation system Research was conducted by direct observation, chart review, staffs interview and servey. Results were as follows: 1) nursing care plans were not used in ongoing care 2) documentation format was primarily narrative and charting was time consuming 3) documentation did not reflect the nursing process 4) patient records were not used as effective communication tool between case manager and part time nurse 5) difficult access to patient record for nurse manager created inefficiency in coordinating 6) documentation of patient education did not describe the precise contents of education, and the responses of the patients and evaluation To solve these problems, new documentation format was developed. With new formats nurses : 1) use standardized care plan which contains nursing diagnosis, ecpected outcome, time frame for evaluation, flow sheet for updating the plans 2) leave one copy of care plan at patient home for mutual agreement with patent and communication among nursing staffs 3) carry one copy of care plan for updating 4) document and evaluate the patient education using education check list keeping in patient's home 5) document nursing process in focus charting visit report 6) carry one copy of visit report 7) have one copy of visit report which was deligated to part time nurses 8) use documentation in direct communication with part time nurse 9) use beeper and memo to promote communication

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A Study of Metadata for Long-Term Preservation of Digital Research Outcome (디지털 연구성과물의 장기보존을 위한 메타데이터에 관한 연구)

  • Jang, Bo-Seong;Nam, Young-Joon
    • Journal of Korean Library and Information Science Society
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    • v.42 no.4
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    • pp.281-309
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    • 2011
  • This research designed and proposed metadata elements for the long-term preservation of digital research outcomes collected and managed in electronic file form. Metadata structure of both domestic and foreign agencies that manage research outcomes and CERIF and PREMIS-preserved preservation metadata were referred to design the metadata elements. The metadata design was divided into research information, bibliographic information and archival information. Research information is divided into project, name and institution, and composed of eight top-level elements and 29 sub-level elements. Bibliographic information is composed of 13 top-level elements as the source of research reports. Archival information is composed of 18 top-level elements and 62 sub-level elements as the elements for context, structure, contents and management process of the electronic records.

A Study on Evaluating the Practicalness of Library and Information Courses in Korea (한국 문헌정보학 교과목의 실용성 평가에 관한 연구)

  • Noh, Young-He;Ahn, In-Ja;Choi, Sang-Ki
    • Journal of Korean Library and Information Science Society
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    • v.42 no.4
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    • pp.5-29
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    • 2011
  • This study proposed to assess courses which are currently offered in the Department of Library and Information Science, and to explore directions for improvement. Based on field librarians' needs and opinions about the courses, we suggested separating the required, core, and elective courses. We proposed six courses including 'Internship', 'Introduction to Library and Information Science', 'Cataloging and Classification', 'Library Management', and 'Information Retrieval' as required courses, and 5 courses including 'Practice in Cataloging and Classification', 'Information Resource and Service', 'Collection Development', 'Digital Library System', 'Introduction to Bibliography' and 'Records Management and Archives' as core courses. Finally, the remaining courses were recommended as selective courses which each department could select depending on their circumstances and faculty. The important components for substantial LIS courses are as follows: timeliness of training topics, expertise of educational contents, professionalism and qualifications of faculty, specialized educational materials, and increasing the major correlation between courses and professors.

The Literary Trends of Herbal Prescription Ukgan-san and its Application in Modern Traditional Korean Medicine (동의보감에 수록되지 않았던 억간산의 문헌상 흐름과 현대 한의학에서의 응용 현황)

  • Cho, Ki-Ho;Kim, Tae-Hun;Jin, Chul;Lee, Ji-Eun;Kwon, Seungwon
    • The Journal of Korean Medicine
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    • v.39 no.3
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    • pp.17-27
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    • 2018
  • Objectives: Ukgan-san does not appear in Traditional Korean Medicine classics. However, it has been used in research and clinical applications in Korea. In this paper, we are aiming to examine the records concerned with Ukgan-san to the present, and announce the present usage state in Korea. Methods: We searched and summarized the contents of previous medical books about Ukgan-san. In order to investigate the current status of utilization of Ukgan-san in Korea, a bibliographic database of Korea, a database of clinical researches, and a database of pharmaceuticals of the Korea Food and Drug Administration were searched. Results: As a result of searching Ukgan-san related documents, Ukgan-san has been developed in China (Ming dynasty). However, its clinical application has been expanded by modern Japanese kampo medicine doctors. In Korea, cases of Parkinson's disease, other movement disorders, and psychiatric disorders have been reported, and randomized controlled trials had been done and planned. In addition, some extracts which are consisted of Ukgan-san are also available. Conclusions: In Korea, Ukgan-san has been influenced by Japan and has been used for clinical and research purposes. The utilization rate in Korea is still small, but the utilization rate will increase according to the results of clinical studies.

Traumatic Diaphragmatic Hernia (외상성 횡경막 허니아)

  • Jang, Bong-Hyeon;Han, Seung-Se;Kim, Gyu-Tae
    • Journal of Chest Surgery
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    • v.20 no.4
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    • pp.839-846
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    • 1987
  • The records of 10 patients with traumatic diaphragmatic hernia seen from November 1977 through July 1987 were reviewed. All the patients had a transdiaphragmatic evisceration of abdominal contents into the thorax. We treated 7 male and 3 female patients ranging in age from 3 to 62 years. In 8 patients, diaphragmatic hernia followed blunt trauma and in 2 patients, stab wounds to the chest. The herniation occurred on the right side in 3 patients and on the left side in 7. All the patients sustained additional injuries: rib fractures [7 patients], additional limb, pelvic and vertebral fractures [6], closed head injury [2], lung laceration [1], liver laceration [1], renal contusion [1], ureteral rupture [1], and splenic rupture [1]. Organs herniated through the diaphragmatic rent included the omentum [6 patients], stomach [4], liver [4], colon [3], small intestine [1], and spleen [1]. For right-sided injuries, the liver was herniated in all 3 patients and the colon, in 1. in the initial or latent phase, dyspnea, diminished breath sounds, bowel sounds in the chest were noted in 4 patients, and in the obstructive phase, nausea, vomiting, and abdominal pain were found in all 3 patients. Two patients had a diagnostic chest radiograph with findings of bowel gas patterns, and an additional 8 had abnormal but nondiagnostic studies. Hemothorax, pleural effusion or abnormal diaphragmatic contour were common abnormal findings. Three patients were operated on during the initial or acute phase [immediately after injury], 4 patients were operated on during the latent or intermediate phase [3 to 210 days], and 3 patients were operated on during the obstructive phase [10 to 290 days]. Six patients underwent thoracotomy, 2 required thoracoabdominal incision, and 2 had combined thoracotomy and laparotomy. Primary suture was used to repair the diaphragmatic hernia in 9 cases. One patient required plastic repair by a Teflon felt. Empyema was the main complication in 2 patients. In 1 patient, the empyema was treated by closed thoracostomy and in 1, by decortication and open drainage. There were no deaths.

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Development of the Clinical Pathway for the Allogeneic Bone Marrow Transplantation Donor Nursing (동종골수이식 공여자 간호를 위한 표준임상지침서 개발)

  • Seol, Mi-Ee
    • Asian Oncology Nursing
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    • v.4 no.2
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    • pp.110-123
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    • 2004
  • The purpose of this study was to develop a clinical pathway for the allogeneic bone marrow transplantation donor. For this study, a conceptual framework was developed through a review of the literature including six steps which are using in Jones Hopkins Hospital. USA. The researcher reviewed 129 medical re-cords of donor who had bone marrow donation between January 2002 to January 2004, to identify the overall service contents required by these patients and to make a preliminary clinical pathway. A content validity test was done for the preliminary clinical pathway, a professional group screened 51 medical re-cords and adopted with 3 hospitalization days as the clinical pathway framework. In the fifth step, clinical pathway test was also done to 7 donors from April 28th to July, 2004. After these processes the final clinical pathway was developed. The results of this study are as follows: 1. The vertical axis of the clinical pathway Includes the following 9 items: vital signs, nursing assessment, activity, diet, intervention, medication, test, consultation and patient teaching. The duration of the horizontal axis was 3days from admission to discharge 2. Analysis of the 129 medical records indicated that the average length of stay was 3 4 days. The medical performance according to the vertical axis in the preliminary clinical pathway consisted of 51 items After clinical validity test, it steel consisted of 51 items in the final form. 3. Clinical Validity test was done to 7 bone marrow donors. During these process, The first patient was deleted because he was out of the criteria the investigate set and 6 patients were used, finally The result of this study indicated all of 7 donors were discharged on expected day. 4. Clinical pathway enables to improve the quality of care, multidisciplinary team work It also helps nursing bone marrow donor, effective education to donor or medical member. The results of this study suggest that clinical pathway may be able to improve the quality of nursing care for bone marrow transplantation donors.

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Study on Special Points in Chimgugyeongheombang (『침구경험방(鍼灸經驗方)』 별혈(別穴)에 대한 고찰)

  • Jang, Heewon;Jung, Sangsun;Eom, Dongmyung
    • Journal of Korean Medical classics
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    • v.30 no.3
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    • pp.1-9
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    • 2017
  • Objectives : Chimgugyeongheombang's Byulhyul, or special points, is a list of extra points, and its acupoint types and positions are different from other books. Its source, however, is kept behind the vale. This paper aims to reveal Byulhyul's contents and source. Methods : Qixiaoliangfang, Jinjiudacheng, and Donguibogam's Gihyul were studied to determine the source of Chimgugyeongheombang's Byulhyul. Results & Conclusions : Chimgugyeongheombang lists a total of 59 special points. It cites 22 meridian points from Qixiaoliangfang, 26 points from Jinjiudacheng, and 36 points from Donguibogam. The Dictionary of Acupuncture records the source of 6 meridian points that aren't found in conventional books, namely the Soongol, Backro, Yeose, Eumdo, Naetaechoong, and Gabgeun points, as Zhenjiujicheng. However, Zhenjiujicheng, in reality, is a book put together with excerpts from three books: Donguibogam, Chimgugyeongheombang, and Leijingtuyi. This means that it's Chimgugyeongheombang that is the source of Zhenjiujicheng. Moreover, all of the points save for Soongol and Eumdo were also used in the acupunctural treatment of 9 diseases including epilepsy. In other words, it can be safely assumed that Heo Im came up with and utilized new special points based on his personal clinical experiences, and this is significant in that he expanded the boundary of the conventional study of acupuncture through his independent experiences and studies.

A study for innovation of Adult nursing assessment tool (간호정보조사지 개선을 위한 연구)

  • Park, Kyung Sook;Chi, Sung Ai;Chung, Hae Kyung
    • Korean Journal of Adult Nursing
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    • v.12 no.1
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    • pp.77-87
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    • 2000
  • This study tried to suggest the basic materials that can be efficiently applied in clinical cases by understanding problems through a content analysis of an adult nursing assessment tool and opinion agreement about nurse's practical usage presently used in the hospital. The study was carried out in 36 attached hospitals in nationwide universities from May to December, 1999, the two hundred and twenty five reports were for analysis. The contents of the collected nursing assessment tool were analyzed. It was found that the tool had been used with various names and content and there were instances of partial omission of a number of items, such as documentation and time records. Other results revealed that they mostly had a systematic classification of items, formation of details a form of a check list, and the effect of saving time. In spite of the adult nursing assessment tool, it was suggested that its style be subdivided according to the specialized of a department and that standardized style be amended and supplemented. The respondents also answered that there had to be education about continuous and sufficient health assessment skills on the physical examination record. The most frequently suggested items to be added were: past history, marital status, patient and caregiver's address and telephone number. It was found that a patient's education career, economic status, religion, hygienic practice, sexual life and hobby were the most frequently omitted items on record. The reason given wes because the items were associated with his/her privacy. These results highlight the importance of analyzing the content with an complete data collection, supplying basic content for a more accurate nursing record, computerization, sharing information and standardization of the form.

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Development of a Critical Pathway of Bullectomy for Spontaneous Pneumothorax Patients (자연기흉으로 폐기포절제술을 받은 환자를 위한 표준진료지침서 개발)

  • Kim, Mi Kyoung;Yu, Seung Hum;Lee, Doo Yun;Son, Young Mo
    • Quality Improvement in Health Care
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    • v.9 no.1
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    • pp.34-51
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    • 2002
  • Background : The purpose for this study is to develop a critical pathway of bullectomy for spontaneous pneumothorax patients. Methods : For this study a conceptual framework of critical pathway was developed through a review of the literature including five critical pathways which are currently being used in USA, and opinions of the critical pathway development team members at Y university hospital. In order to identify the service contents required by these patients and to draw up a preliminary critical pathway, 33 cases of medical records of patients who had received bullectomy for spontaneous pneumothorax between September, 2000 to August, 2001 at the Respiratory Center of Y university hospital in Seoul was analyzed. Results : In order to test the clinical validity of the preliminary critical pathway, it was applied to ten patients who had received bullectomy for spontaneous pneumothorax from October, 2001 to December, 2001. The average discharge day was 4.89th post operation day, six patients discharged on the fourth post operation day which was the expected day, one patients discharged one day earlier than the expected day, one patient discharged three days later than the expected day, and one patient discharged six days later than the expected day. There were variances between the critical pathway and the actual practice. The variances came from tests, medications, and treatments. One item that showed variance in clinical applications was complemented, and three items were decided not to be corrected for the final determination of the critical pathway. Conclusion : This critical pathway is applicable to the care of patients with bullectomy for spontaneous pneumothorax, but it needs more clinical applications to grasp varied variances.

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Comparisons of Dietary Intakes and Body Composition with Different Sexual Maturation Velocities in Korean Girls of Early Pubertal Age (성 성숙 속도가 다른 사춘기 초기 여자 어린이의 체구성 및 식생활 비교)

  • Chang, Hoon;Park, Min-Kyung;Paik, Hee-Young;Joung, Hyo-Jee
    • Journal of Nutrition and Health
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    • v.40 no.1
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    • pp.58-68
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    • 2007
  • The associations between dietary, body composition and sexual maturation were investigated among Korean girls of pubertal age in this study. Dietary intakes were collected by 3 day food records, body compositions were measured by bio-impedence analyzer and sexual maturation stages were determined with a self-administrated questionnaire using Tanner stages in 1,114 girls 9-13 years of age. Girls were divided into early maturation (EM) and late maturation (LM), based on the comparative maturation stages of breast and pubic hair among the same age groups by months. Subjects were excluded if their stage of maturation could not be divided into early and late groups. EM and LM groups consisted of 42.8% and 38.9% of subjects by breast stage and 67.4% and 22.8% by pubic hair stage. Girls in LM group had significantly lower in height, weight and bone mineral contents (p < 0.05). When nutrient densities of average daily intake of the two groups were compared, folate density was significantly higher among the LM group of breast stages (p < 0.01), and Ca, P, K, Vit. $B_1$, Vit. $B_2$ and folate densities were significantly higher among the LM group of pubic hair stages (p < 0.05). These results show that intakes of some micronutrients differ between children with faster and slower sexual maturation velocities at early pubertal stages. More longitudinal studies are needed to confirm whether such differences are consistent throughout the pubertal period.