• 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.

• The Transactions of The Korean Institute of Electrical Engineers
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• v.57 no.3
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• pp.501-506
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• 2008

Medical environments incorporate complex and integrated data networks to transfer vast amounts of patient information, such as images, waveforms, and other digital data. To assure interoperability of images, waveforms and patient data, health level seven(HL7) was developed as an international standard to facilitate the communication and storage of medical data. We also adopted medical waveform description format encoding rule(MFER) standard for encoding waveform biosignal such as ECG, EEG and so on. And, the study converted a broad domain of clinical data on patients, including MFER, into a HL7 message, and saved them in a clinical database in hospital. According to results obtained in the test environment, it was possible to acquire the same HL7 message and biosignal data as ones acquired during transmission. Through this study, we might conclude that the proposed system can be a promising model for electronic medical record system in u-healthcare environment.

• Korean Business Review
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• v.13
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• pp.207-221
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• 2000

In this era of changing system, we may learn lesson from newly developed Uniform Electronic Transation Act(UETA) in 1999. Korea has its counterpart as the Basic Electronic Transaction Act and Electronic Signature Act made by 1999. While UETA stresses on transaction law between individuals, that of Korean stresses on the role of government in electronic transaction. Both laws have the common definitions as electronic record, electronic signature, however, UETA has its own definitions such as automated transaction, computer program, electronic agent, information, information processing system, and security procedure. Especially, transferable record in section 16 is one of the most unique concept which Korean law does not provide. Korean government is planning to introduce electronic note in the near future, which will make unprecedented reform in Korean financial industry. Since Korean law does not have such a concept as electronic note, revision of the law is expected soon. Korean law has its specialty which puts stress on cyber mall, authentication agency, and consumer protection. In U.S., the interpretation of law by court is important when they have disputes according to common law traditon. Studies on cases on disputes in U.S. is needed most for Korean application.

• Journal of the Korean BIBLIA Society for library and Information Science
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• v.34 no.4
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• pp.259-283
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• 2023

This study acknowledges that prevailing regulation concerning for the long-term preservation of electronic records focus mainly on document types, neglecting the preservation of electronic records from various administrative information systems. With the growing interest in data management in the era of big data, it is imperative to establish clear standards for the long-term preservation of datasets. The choice of preservation format for electronic records is based on the specific standards for each type of electronic record. These standards are formulated according to the significant properties relevant to the electronic record type. This study aims to identify the significant properties of electronic records of each record type, before creating specific preservation format selection criteria for these record types. To achieve this, we reviewed and analyzed R&D studies by the National Archives of Korea and the NARA in the United States. As a result of the research, 9 significant properties were identified for database-type entities, and 7 significant properties were identified for structured data-type entities.

• 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.

• International Commerce and Information Review
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• v.9 no.3
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• pp.287-304
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• 2007

Determination of the time and place of dispatch and receipt of electronic messages is an important element of the operation of many rules of law, particularly the timing of formation of the contract. In this paper, I reviewed interpretation and application of time and place of dispatch and receipt of electronic records in electronic transactions under the UNCITRAL(United Nations Commission on International Trade Law) Model Law on Electronic Commerce, USA Uniform Electronic Transactions Act and Korea Electronic Transactions Act. Time of dispatch and time of receipt are effective when received. The sender has the burden to prove that the electronic record is sent successfully to the information process system of the recipient. Therefore, to safety electronic transactions, the sender needs to request a confirm notice for receipt to the recipient when the electronic record is sent like the provisions of UNCITRAL Model Law on Electronic Commerce and Korea Electronic Transactions Act. By requesting the above, the sender is able to take precautionary measures for damage according to the failure of dispatch and receipt of the electronic records.

• Journal of Information Management
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• v.38 no.3
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• pp.161-181
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• 2007

Since 1990s, major corporations and public organizations have actively implemented their own knowledge management, by which they develop new businesses and enhance organizational efficiencies. However, their knowledge management processes are sometimes isolated or mismatched with their record management systems and reveal many problems to operate and maintain them effectively. This paper analyzes the current status and problems of corporate knowledge management. Next, it proposes the necessity and the methods to integrate knowledge management and records management in order to transform corporate records as useful knowledge resources. Aligning corporate record management strategies with knowledge management policies enables to improve the management of corporate electronic records. Especially, the implementation of record retention schedule based on the life cycle management of records is emphasized as a KM governance strategy and method to manage corporate records effectively.

• Journal of Korean Clinical Nursing Research
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• v.15 no.3
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• pp.107-116
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• 2009

Purpose: This study was conducted to evaluate the record completeness of the nursing process in the Electronic Nursing Record(ENR) in a university hospital. Methods: We compared nursing statements documented in 2004 with those from the year 2007, given the fact that the ENR system had been utilized since 2004. The ENRs of 35 gastrectomy patients in each year were selected for evaluation. The selected data were 11,822 nursing statements in 2004 and 27,870 in 2007. Results: The number of nursing records which documented the whole nursing process completely was 4,010 (48.3%) in 2007, whereas 513 (5.9%) in 2004 (p<.001). The number of incomplete records in 2004 was 8,142 (94.1%), while 4,300 (51.7%) in 2007 (p<.001). The number of nursing diagnoses was 846 in 2004 and 4,313 in 2007, which increased in number more than 5 times. The most frequently used diagnoses were 'pain', 'risk for infection' and 'risk for ileus' in both years. Conclusion: There was a significant increase in the record completeness on nursing process in 2007 compared to the records in 2004. The reasons for this increase are attributed to nurse training for encouraging to complete recording and nursing record auditing.

• Perspectives in Nursing Science
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• v.5 no.1
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• pp.33-43
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• 2008

Objective: This study explored the reuse of data captured into an electronic nursing record system using the International Classification for Nursing Practice to support nursing research of inpatient's falls. Methods: Risk factors relevant to inpatients falls ;n an acute setting were identified from the literature review. Four risk assessment tools and two risk identification studies were selected. To examine the availability of coded data in an electronic nursing record system for the identified fall fisk factors, we reviewed 11.319 hospital-day records of 118 patients who were reported by the self-report system. Results: We identified 24 fall risk factors of five categories from the literature review, which were used to identify the standard nursing statements addressing fall risks. One hundred thirty five nursing statements were searched from the hospital's nursing data dictionary of statements and were matched with 14 fall fisk factors. Using the 135 statements. we found that mental status, catheter of drip in situ, abnormal gait, insomnia, surgical procedure. and dizziness/vertigo appeared frequently in the nursing records of inpatients with fall s. Also we found 6 risk factors more through the record review. Conclusion: The electronic records would be a good research source for inpatients' falls. Specifically international classification for nursing practice based nursing record system has the potential for promoting clinical researches.

• Journal of Digital Convergence
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• v.11 no.8
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• pp.293-302
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• 2013

So far, DW(data warehouse) of hospital has been used as tool for analyzing patient-focused data. However, EMR(Electronic Medical Record) is established these days, so informal data which is record and video record could be useful to get some information for patient remedy, not as DW data. This study claims that need of establishing treatment-focused DW, not for hospital administration-focused DW which has been used lots of hospital DW. Also we discussed how CDW can be applied for real medication situation. At last, we deduct a relation past record of sick and wounded patient as Thesaurus searching method by real hospital data for establishing base of early-treatment system.