• Journal of Korean Clinical Nursing Research
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• v.16 no.3
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• pp.123-132
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• 2010

Purpose: This study was done to analyse nursing records to identify the nature of pain and actual conditions of pain management in patients hospitalized in one university hospital. Methods: The participants in this study were 783 patients with a length of stay of 3 to 30 days who were discharged from medical wards between June 1 and June 30, 2009. Data on nursing records related to pain management from these patients were reviewed using the Electronic Nursing Records (ENRs) system. Results: Over 30 percent of 10,702 nursing records related to pain assessment had no record on region, severity, nature or frequency of pain. About 30 percent of 13,638 nursing records related to pain intervention showed non-drug pain management techniques. Conclusion: Accurate and complete records on pain assessment including region, severity, nature and frequency of pain are essential to effectively manage patients' pain. Improvement in ENRs system for better assessment and management of pain is required as well as education programs on a standardized measuring tool for both nurses and patients.

• Journal of Preventive Medicine and Public Health
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• v.48 no.5
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• pp.239-248
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• 2015

Objectives: The purpose of this study was to assess the inter-rater reliability and intra-rater reliability of medical record review for the detection of hospital adverse events. Methods: We conducted two stages retrospective medical records review of a random sample of 96 patients from one acute-care general hospital. The first stage was an explicit patient record review by two nurses to detect the presence of 41 screening criteria (SC). The second stage was an implicit structured review by two physicians to identify the occurrence of adverse events from the positive cases on the SC. The inter-rater reliability of two nurses and that of two physicians were assessed. The intra-rater reliability was also evaluated by using test-retest method at approximately two weeks later. Results: In 84.2% of the patient medical records, the nurses agreed as to the necessity for the second stage review (kappa, 0.68; 95% confidence interval [CI], 0.54 to 0.83). In 93.0% of the patient medical records screened by nurses, the physicians agreed about the absence or presence of adverse events (kappa, 0.71; 95% CI, 0.44 to 0.97). When assessing intra-rater reliability, the kappa indices of two nurses were 0.54 (95% CI, 0.31 to 0.77) and 0.67 (95% CI, 0.47 to 0.87), whereas those of two physicians were 0.87 (95% CI, 0.62 to 1.00) and 0.37 (95% CI, -0.16 to 0.89). Conclusions: In this study, the medical record review for detecting adverse events showed intermediate to good level of inter-rater and intra-rater reliability. Well organized training program for reviewers and clearly defining SC are required to get more reliable results in the hospital adverse event study.

• Journal of The Association for Neo Medicine
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• v.1 no.2
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• pp.31-37
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• 1996

${\ulcorner}Volume\;1{\lrcorner}$ of ${\ulcorner}$Medical Records as a Guide to Clinical Works${\lrcorner}$, written by Ye Tian Shi, showed some clinical cases of dizziness. In this study, his diagnosis and treatment was studied with 16 clinical cases of dizziness with pathogenic factor, pathogenesis and symptoms of dizziness. Ye Tian Shi thought that phlegm, fire, wind and insufficiency were the causes of dizziness and phlegm-fire, phlegm-fire-wind, wind-phlegm and insufficiencyfire-wind were the causes of dizziness, clinically. Dizziness is caused when the body is in condition of excess in the upper and deciency in the lower. The acompanying clinical symptoms of dizziness are endogenous wind, fire of deficiency type, phlegm wind and phelegm fire. For the treatment of dizziness, Ye Tian Shi used the combination of medicines with some modifications by the cases for phlegm, fire, wind and insufficiency. He also encouraged the mental therapy for the treatment of dizziness. He emphasized the early treatment of dizziness to prevent hemiplegia after apoplexy. It can be postulated from Volume 1 of ${\ulcorner}$Medical Records as a Guide to Clinical Works${\lrcorner}$, diagnosis and treatment of symptoms and illness of Ye Tian Shi was strictly based on actual clinical cases.

• The Journal of Korean Medical History
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• v.24 no.1
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• pp.17-30
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• 2011

King Hyeonjong, the 18th king of the Chosun Dynasty, reigned for 15 years. During his reign, he underwent a political incident named the Controversy about the Confucian Funerary Rituals. This incident was carried out 2 times: 1 time during early days of his reign and 1 time during later days. Although it started out as a trivial dispute over the period Queen Dowager Ja-eui(stepmother of King Hyojong, Hyeonjong's father) had to wear a mourning dress, it advanced to a political incident concerning the acknowledgement of King Hyeonjong's legitimacy and political pride of the king and the vassals. Although existing researches focus on the historical context of this incident, this study focuses on the relationship between this incident and King Hyeonjong's disorders. During the First Controversy about the Confucian Funerary Rituals, King Hyeonjong was treated for various symptoms concerning hypochondria. During the Second Controversy, he suffered from septicemia as well as diabetic complications. This study is based on the texts of "The Daily Records of Royal Secretariat of Chosun Dynasty".

• Journal of Korean Academy of Fundamentals of Nursing
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• v.21 no.2
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• pp.151-161
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• 2014

Purpose: The purpose of this study was to identify the risk factors that influence surgical site infections after surgery. Methods: This study was a retrospective research utilizing Electronic Medical Records. Data collection targeted 4,510 adult patients who had 8 different kinds of surgery (gastric surgery, colon surgery, laparoscopic cholecystectomy, hip & knee replacement, hysterectomy, cesarean section, cardiac surgery) in 4 medical care departments, at one general hospital between January 2006 and December 2011. Multivariate logistic regression analyses were used to identify the risk factors affecting surgical site infections after surgery. Results: Risk factors for increased surgical site infection following surgery were confirmed to be age (OR=1.59, p<.001), BMI (Body Mass Index)(OR=1.25, p=.034), year of operation (OR=2.45, p<.001), length of operation (OR=3.06, p<.001), ASA (American Society of Anesthesiology) score (OR=1.36, p=.025), classification of antibiotic used (OR=2.77, p<.001), duration of the prophylactic antibiotics use (OR=1.85, p<.001), and interaction between classification of antibiotic used and duration of the prophylactic antibiotics use (OR=1.90, p=.016). Conclusions: Results suggest that risk factors affecting surgical site infections should be monitored before surgery. The results of this study should contribute to establishing effective infection management measures and implementing surveillance systems for patients who have actual risk factors.

• Journal of Yeungnam Medical Science
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• v.39 no.4
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• pp.341-343
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• 2022

To determine the vertical dimension and centric relation during the construction of implant overdentures, the record base and wax rim may need to be adjusted. The conventional method has several drawbacks, as it requires repeated tightening and loosening of the impression coping. Here, we report a useful and novel method for interocclusal records using the healing abutments in implant overdentures. Our case demonstrates that this method is easier and simpler and prevents gingival collapse.

• 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.

• Quality Improvement in Health Care
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• v.15 no.1
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• pp.123-133
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• 2009

Background : The principal diagnosis has been used in many different fields such as hospital statistics, medical research, insurance claim, national health statistics and so on. Some principal diagnoses have a relatively low level of reliability in the medium-sized hospitals. The purpose of this study is to identify the reliability level of principal diagnoses and to suggest ways to improve reliability of the principal diagnosis. Method : Data were collected from a medium-sized hospital located in Pusan. The discharge summaries on 323 patients who were discharged in January, 2008 and the outpatient summaries on 251 patients who visited the hospital on March 28, 2008 were collected, and descriptive analysis was performed using SPSS version 12.0K. Result : The findings are the followings: (1) the diagnostic consistency rate between medical records and doctors' was 92.0%; (2) the diagnostic consistency rate between medical records and insurance claims was 86.1%; (3) the diagnostic consistency rate between doctors' diagnoses and insurance claims was 80.2%. The evidence seems to indicate that some principal diagnoses have reliability problems in the medium-sized hospitals. Conclusion : The results of this study suggest the followings: (1) employees should be trained and supervision of hospital activities are needed; (2) network systems should be constructed for each department; (3) professions need to be fostered (4) doctors' awareness of medical records should be changed.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.20 no.6
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• pp.1-8
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• 2019

Medical information is an important personal information for patients, and it must be protected. In particular, when medical personnel approach electronic medical records, authentication for enhanced security is essential. However, the existing public certificate-based certification model did not reflect the security characteristics of the electronic medical record(EMR) due to problems such as personal key management and authority delegation. In this study, we propose a fingerprint recognition-based authentication model with enhanced security to solve problems in the approach of the existing electronic medical record system. The proposed authentication model is an EMR system based on fingerprint recognition using PEMS (Private-key Escrow Management Server), which is applied with the private key commission protocol and the private key withdrawal protocol, enabling the problem of personal key management and authority delegation to be resolved at source. The performance experiment of the proposed certification model confirmed that the performance time was improved compared to the existing public certificate-based authentication, and the user's convenience was increased by recognizing fingerprints by replacing the electronic signature password.

• Journal of Acupuncture Research
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• v.31 no.2
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• pp.145-152
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• 2014

Objectives : This study aimed to assess the effectiveness and safety of Taegeuk acupuncture for patients with chronic musculoskeletal pain. Methods : A retrospective analysis of the electronic medical records of Pusan National University Korean Medicine Hospital from March 2012 to March 2013 was performed. Eligible cases were outpatients who had received at least six sessions of Taegeuk acupuncture for their pain and had agreed to the use of their medical records for research purposes. Pain levels, heart rate variability, and patients' perceptions of the safety of acupuncture were investigated through the medical records and follow-up telephone interviews. Results : Fifteen cases were selected for analysis. All had suffered from musculoskeletal pain for at least one year. After six sessions of Taegeuk acupuncture, the average score on the pain numeric rating scale decreased from $6.7{\pm}2.0$ to $2.9{\pm}2.2$(a 43 % reduction). Follow-up telephone interviews revealed that patients experienced no adverse event after Taegeuk acupuncture. Conclusions : Patients with chronic musculoskeletal pain showed a reduction of more than half of the baseline pain after six sessions of Taegeuk acupuncture. However, the beneficial effects observed in this retrospective analysis should be interpreted with caution due to selection and recall bias. Further randomized controlled trials of Taegeuk acupuncture for chronic musculoskeletal pain are warranted.