• 대한한방소아과학회지
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• 제21권1호
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• pp.53-85
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• 2007

Objectives : The Medical Records(醫案) are important materials in studying the developmental process of Korean Traditional Medicine. The purpose of this study was to investigate the medical records which were described in Gupyubang(及幼方), the first Korean book that specialized in pediatrics. Methods : 85 Medical records about medical traits of diagnosis and treatments in Gupyubang were analyzed and those were translated in Korean. Results : Medical records were analyzed as follows; The number of Male was 76 and the number of Female was 9. Prepubertal period was 16 and preschool period 14. Acute febrile convulsion was 6. Measles and blood symptom was 5. Ring worm pain, vomiting & diarrhea, colic pain was 4. Most of them were self treatment except one. 77 cases were improved and 6 cases were dead or worse. The medical records used oral medication, external medication, acupuncture, moxibustion and surgical manners. Conclusion : This study showed that Gupyubang is a experiential book and alse the medical records in Gupyubang was usefulness and had practical value.

• 한국병원경영학회지
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• 제8권2호
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• pp.111-129
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• 2003

This study discusses the direction of legislation to strengthen the legal protection of medical records privacy in information age. The legislation trends on privacy protection of medical records in European Union and United States are analysed and the current law and regulation of Korea on medical records are compared. The issues discussed include the ownership of medical records, the patient's right of access to medical records, medical information publication for other than treatment or insurance processing use, confidentiality responsibility of provider organizations, medical information management in provider organizations, penalty for the unlawful use of patient information. This study concludes that the patients' right on medical record and provider organization's responsibility in processing patient information should be strengthened in order to protect patients' privacy and to conform to the international standard on medical record protection in the information age.

• 한국기록관리학회지
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• 제13권3호
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• pp.151-171
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• 2013

본 연구는 서울 시내 5개 대학병원의 의무기록 관리자들이 생각하는 전자의무기록시스템 구현 시 기록관리 메타데이터 표준 요소의 중요도를 설문조사하였다. SPSS 20.0(ver)을 이용하여 중요도 점수는 5점 척도의 평균으로 도출하여 순위를 정하였고 응답자 특성에 따른 중요도 차이를 분석하였다. 90%의 응답자가 국가기록원에서 기록관리 메타데이터 표준을 고시하고 있음을 모르고 있었다. 가장 중요도가 높은 요소는 '비밀등급 설정' 이었으며 '의무기록 접근행위종류', '내부직원 권한 설정', '의무기록 이용접근자' 요소가 그 다음 순위를 보여 기록정보보호 측면에서의 관리 기능 강화를 필요로 함을 알 수 있다. 개인 프라이버시 보호를 위하여 '외부공개'는 중요도가 낮은 관리요소로 평가되었으나, 전자의무기록 도입 7년 이상인 기관의 관리자들은 7년 미만의 관리자 보다 유의하게 이 세 가지 요소의 중요도를 높게 평가하였다. 이는 정보 축적에 따라 의학연구, 의학교육 등에서의 정보 이용에 대한 관리 기준과 시스템상의 적용이 필요함을 보여준다.

• Journal of the Korean Data and Information Science Society
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• 제14권4호
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• pp.817-824
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• 2003

We employed a hierarchical document classification method to classify a massive collection of electronic medical records(EMR) written in both Korean and English. Our experimental system has been learned from 5,000 records of EMR text data and predicted a newly given set of EMR text data over 68% correctly. We expect the accuracy rate can be improved greatly provided a dictionary of medical terms or a suitable medical thesaurus. The classification system might play a key role in some clinical decision support systems and various interpretation systems for clinical data.

• 대한한의학회지
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• 제15권2호
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• pp.306-320
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• 1994

An account book of medical treatment is a form of collection materials for diagnostic standardization, and it is a basis of standardization, standardization of medical records is a preconsideration of each standardization. But an account book of medical treatment is only a kind of form for recording medical treatment, therefore standardization of medical treatment eventually holds the key to the standardization of recording charts. However until now we have gradually reformed medical records in accordance with individual characters of medical treatment, and didn't have even standard sheme of medical records, also medical terms for medical records had an inconsistency of redescription and reiterative representation for an identical terms in all parts of the East learning, medical terms for medical records didn't unity. To make better this realities, standardization study used orginated system in the process of existing study, it can get ready the basis of discussion between O.M.D and O.M.D. it can make analysis of diagnostic course and can clearly understand usable information by diagnostic course. for that reason we hope that the basis of standardization is accomplished. And in advance of study for this standardization we have to analysis the course of medical treatment with demonstration of roof, first of all we have to study term definition by diagnostic course and prepare basis by diagnostic course. because this study have limits of indivisual study, it needs to long and synthetic investigation in Association levels. Although we cann't completely alternate with methods of measurement which relyed on individual mastery, if we exclude erroes of individual measurement through mechanization and verify results of diagnosis through keynotes, we can realize standardization of medical treatment with demonstration of proof and in this process we can use medical records as a tool collecting exact data, also we can realize standardization of drawing up medical records.

• 한국의사학회지
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• 제21권2호
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• pp.1-11
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• 2008

"承政院日記" is a journal written by the scribes belonging to the Royal Secretariat and consists of objective and detailed records about events, dialogs, and actions that happened in the presence of the king and also collections of all the documents output by the Royal Secretariat. The medicine-related records in "承政院日記" are mainly records of the medical examination and treatment of the king and the royal family and related documents of operation. Of the many different entries involved with clinical practices, this study focuses on the medical examination and treatment of the king. Through the case studies displayed in the clinical records of "承政院日記", trial and error of its time as well as clinical results can be verified. Sorting out of affirmative tradition that could not be handed down due to institutional interruption is also made possible through comparison of effective treatment methods of late Chosun dynasty including patterns or distinctive methods of treating specific diseases against their counterparts in Traditional Korean Medicine of today.

• Asian Pacific Journal of Cancer Prevention
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• 제14권3호
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• pp.2107-2111
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• 2013

Objectives: To investigate data agreement of cancer registries and medical records as well as the quality of care and assess their relationship in a 5-year period from 2006 to 2011. Methods: The present cross-sectional, descriptive-analytical study was conducted on 443 cases summarized through census and using a checklist. Data agreement of Nemazi hospital-based cancer registry and the breast cancer prevention center was analyzed according to their corresponding medical records through adjusted and unadjusted Kappa. The process of care quality was also computed and the relationship with data agreement was investigated through chi-square test. Results: Agreement of surgery, radiotherapy, and chemotherapy data between Nemazi hospital-based cancer registry and medical records was 62.9%, 78.5%, and 81%, respectively, while the figures were 93.2%, 87.9%, and 90.8%, respectively, between breast cancer prevention center and medical records. Moreover, quality of mastectomy, lumpectomy, radiotherapy, and chemotherapy services assessed in Nemazi hospital-based cancer registry was 12.6%, 21.2%, 35.2%, and 15.1% different from the corresponding medical records. On the other hand, 7.4%, 1.4%, 22.5%, and 9.6% differences were observed between the quality of the above-mentioned services assessed in the breast cancer prevention center and the corresponding medical records. A significant relationship was found between data agreement and quality assessment. Conclusion: Although the results showed good data agreement, more agreement regarding the cancer stage data elements and the type of the received treatment is required to better assess cancer care quality. Therefore, more structured medical records and stronger cancer registry systems are recommended.

• 대한한의학원전학회지
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• 제21권3호
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• pp.127-145
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• 2008

We have known that "Chimgudaeseong(鍼灸大成)" had been written by Yanggyeju(楊繼洲) in Myeong(明) Dynasty. And it had been the only text book of acupuncture & moxibustion for 300 years. This book is composed of 10 chapters dealing almost all the medical theories of that times. This book is so enormous that it is hard to understand essential ideas of author. The reading medical records is one of the best way to develop one's abilities of curing a disease without clinical practice. so we can't help dealing with medical records, because it is one of important method of understanding Oriental Medicine. On this study, we investigate a objective method on understanding medical records in "Chimgudaeseong(鍼灸大成)".

• 기본간호학회지
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• 제13권1호
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• pp.24-32
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• 2006

Purpose: This study was a comparative review of the computerized nursing records and paper-based nursing records to examine effects of a nursing process documentation system focusing on patients who have had stroke. Method: First, the researchers collected all the foci from the computerized records and the paper-based records. They selected ten nursing foci, used frequently in both groups and analyzed the number of foci per patient, appropriateness of foci, the number of nursing activities per nursing focus and whether outcomes were described or not in the nursing record. Results: There was fewer errors in nursing diagnosis selection, and a larger number of activities in the records than trle paper based ones. Also, there was a better description of the nursing outcomes in the computerized records. Conclusion: This study suggests that the computerized nursing records is significantly effective in increasing accuracy of the nursing care plan and quality of the nursing record.

• 한국의사학회지
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• 제25권1호
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• pp.23-41
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• 2012

'The Daily Records of Royal Secretariat of Chosun Dynasty' is a record created in Seung-jeong-won, a secretariat for kings of Chosun, and is a government record which holds conversations between kings and their vassals as it is. General affairs in terms of the royal family and national administration are recorded, but what is more important is the records on diseases of kings and how they were treated. This study is to look into diseases from which King Injo(1959-1649) had suffered based on the records written during the time of his reign, which was from 1623 to 1649. Also, the "curse incident" and the death of prince Sohyeon, son of King Injo, both of which had significant influence on the health of the king, were reviewed in relation to the disease records.