• Korea Journal of Hospital Management
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• v.15 no.1
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• pp.1-12
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• 2010

This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor's admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor's admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor's admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking (p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.

• Korea Journal of Hospital Management
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• v.16 no.2
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• pp.19-30
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• 2011

This study aims to present ways to enhance the stabilization of electronic medical records, ensure the commitment to filling in information of the medical record and improve the overall quality Electronic Medical Record(EMR) information. For that purpose, the present state of the incomplete record rate and the doctor's satisfaction in Electronic Medical Record(EMR) have been surveyed by comparing and analyzing Paper-based Medical Record(PMR) and Electronic Medical Record(EMR). The survey was conducted on 31 doctors in charge of EMR system and each PMR and EMR inpatients were collected for a period of 5 months and analyzed. The results showed that the doctor's satisfaction level was higher for EMR, and the rate of incomplete record appeared to be lower in EMR in departments of both internal and external medicine. In this context, it can be said that the higher efficiency of EMR helped accomplish the increase in commitment to completing medical record information and improve the quality of the data.

• The Korean Journal of Health Service Management
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• v.6 no.4
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• pp.61-72
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• 2012

The purpose of this study was to propose how to improve and develop the college curriculum of medical record administration, satisfying requirements from hospitals having medical record administrators. For the purpose, this researcher surveyed medical record administrators serving at hospitals located in Busan, Changwon, Masan and Jinju. Finally analyzed were responses from 100 medical recorders. The frequency of searching medical records to support information use was statistically different among hospitals according to the number of sick beds(p=.041), or $3.16{\pm}1.75$ for fewer than 300 sick beds, $4.28{\pm}2.42$ for 300 to 500 and $4.86{\pm}3.18$ for more than 500. The college course that was regarded as most important by most of the surveyed medical record administrators, or 53(37.2%) was medical terminology, followed by statistics by 36 of the respondents(18.5%) and EMR, 25(12.8%) in order. To make EMR truly effective requires reforming the university curriculum of medical record administration and giving more attention and more supports to training for better computerization, realizing that medical record administrators serve as a true manager of health and medical information, not a person who just paper-based medical information. In addition to managing health and medical information, medical record administrators are expected to have more roles in the future, for example, providing high-quality clinic knowledge and medical information that are necessary for efficient hospital management and medical research to survive competition.

• 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.5 no.3
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• pp.127-133
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• 2009

The pre-existing medical treatment was done in person between doctors and patients. EMR (Electronic Medical Record) System computerizing medical history of patients has been proceed and has raised concerns in terms of violation of human right for private information. Which integrates "Identification information" containing patients' personal details as well as "Medical records" such as the medical history of patients and computerizes all the records processed in hospital. Therefore, all medical information should be protected from misuse and abuse since it is very important for every patient. Particularly the right to privacy of medical record for each patient should be surely secured. Medical record means what doctors put down during the medical examination of patients. In this paper, we applies fingerprint identification to EMR system login to raise the quality of personal identification when user access to EMR System. The system implemented in this paper consists of embedded module to carry out fingerprint identification, web server and web site. Existing carries out it in client. And the confidence of hospital service is improved because login is forbidden without fingerprint identification success.

• 대한예방의학회:학술대회논문집
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• 1999.10a
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• pp.73-74
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• 1999

• 대한예방의학회:학술대회논문집
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• 1999.10a
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• pp.71-72
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• 1999

• Journal of the Korean Society for information Management
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• v.29 no.3
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• pp.257-285
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• 2012

As the electronic medical records systems (EMRs) are introduced into the hospitals in Korea and the needs of chief stakehoders of medical records are changed, the environments related to creating and managing medical records has been changed dynamically. At this moment it might be meaningful to examine medical records based on records management principles rather than information management principles. The purpose of this paper is to apply the KS X ISO 1549 standards, which covers the principles of records management, to hospital medical records management and assess the current quality of medical records management, and define a few tasks of improvement for hospitals. To achieve this goal, this study has performed following activities: Firstly, principles that could be applied to medical records management were prepared for each record management steps described in the standards, such as capture, registration, classification, storage, access, trace and disposition, and 22 principles were selected from those 7 steps of the record management. Secondly, the Y hospital, which is affiliated with a medical school in Seoul, was chosen to evaluate the current situation regarding medical records management. The department head of the medical records management team in Y hospital was interviewed and the present status was evaluated according to each principle. Thirdly, tasks for improvement were suggested, in such stages as access, trace and disposition. With this study as a cornerstone, useful implications are expected to be gathered from future studies that apply standards for metadata of records, management systems for records, and record management systems to medical record management in hospitals.

• Journal of the Semiconductor & Display Technology
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• v.13 no.2
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• pp.63-66
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• 2014

Managing electronic medical record is very difficult, because the currently electronic medical system is not designed standard that is uniform and proper. In this paper, in order to overcome this situation, we propose meta-data for the management of the electronic medical record as a single system. To this end, we first analyzed the research on electronic medical records and related standards. Second, we, on the basis of the analysis result, abstracted electronic medical record and entities related on electronic medical, and we designed an entity-relationship model. And finally, we have to complete the meta-data through the setting attributes in this entity-relationship model. Through this study, it was possible that we can complete metadata highly expressive medical records, and suggest an alternative for problem of current medical records systems.

• Quality Improvement in Health Care
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• v.5 no.1
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• pp.16-26
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• 1998

Background : As many previous studies proved, the quality of medical record is thought to reflect the quality of care. In this study, we analyzed the relationship between the quality of record and some factors influencing the quality of record, especially the commitment of the attending physician. Method : We developed checklist for evaluation of medical record with 36 criteria. 300 inpatient records of 10 attending physicians' patients were evaluated and the quality' of records were scored. The attending physician's commitment to medical records were scored by 34 residents. The relationship of the quality of records with physician's commitment to records, and some other factors were analyzed. Results : More than 75% of the immediate postoperative notes on the progress note were missed. More than 69% of the contents of explanation about the procedures on the consent form or on the other forms were also missed. The physician whose quality score of records was the highest(78.9) got the highest commitment score. The score of attending physician's commitment to the record, and his seniority were positively related with the quality score of his medical records when number of patients and department were adjusted. Conclusion : The quality of the 5 forms of the record reviewed were evaluated as moderate or excellent except 2 or 3 items. The quality of record was positively related with the attending physician's commitment to the record, and the seniority of the physician.