• Title/Summary/Keyword: quality of medical record

Search Result 149, Processing Time 0.025 seconds

Analysis of direct medical control conducted to 119 emergency medical technicians in an emergency medical information center (119구급대원에게 시행한 일개 응급의료정보센터의 직접의료지도에 관한 분석)

  • Seo, Ha-Yan;Lee, Kyoung-Youl
    • The Korean Journal of Emergency Medical Services
    • /
    • v.16 no.3
    • /
    • pp.29-43
    • /
    • 2012
  • Purpose : The goal of the present study is to provide the basic information to medical control which is the most important improving factor of pre-hospital medical treatment. Method : A total of 749 records of direct medical control were collected from 119 EMTs in emergency medical information center of Daejeon, Chungcheongnam-do and Chungcheongbuk-do from March 1, 2010 to February 28, 2011. Results : The 119 EMTs should record the level of qualification of EMT and general patient history taking precisely when they receive direct medical controls. The doctors should take medical controls within the task range of qualification of EMTs. Conclusion : It is necessary to establish the guideline of medical direction and protocol of prehospital emergency care. The quality improvement of pre-hospital emergency services will be possible by the guideline and protocol.

A Convergence study on the effects of satisfaction of nurses using the Electronic Medical Record system on job stress (전자의무기록시스템을 이용하는 간호사의 만족도가 직무스트레스에 미치는 영향에 관한 융합연구)

  • Ha, Yun-Ju
    • Journal of the Korea Convergence Society
    • /
    • v.8 no.5
    • /
    • pp.69-78
    • /
    • 2017
  • This is a convergence study to provide an effective way of managing nurses' job stress by improving nurse satisfaction through an integrated identification of the effect satisfaction level on job stress for nurses using an electronic medical record(EMR) system. The data were collected from August 1 to September 1, 2014. The participants were 377 nurses from C university hospital of G metropolitan city were analyzed using SPSS 21.0. The result shows that job stress decreases as nurses' satisfaction level of using the EMR system increases. Thus, a practical job stress mediation program should be developed to continuously enhance nurses' satisfaction with the EMR system, which is expected to shorten the nursing record writing time and improve the quality of nursing service for patients. Furthermore, to improve the satisfaction with the EMR, appropriate management, such as continuous nursing education on the EMR system, will be needed.

A Comparison of Efficiency between Computerized Nursing Records and the Paper-based Nursing Records - focus on patients with a stroke - (전산간호기록과 서면간호기록의 효율성에 관한 비교연구 - 급성 뇌졸중 환자의 간호기록 중심으로 -)

  • Sung Young-Hye;Cho Myung-Sook;Choi Bok-Yeon;Jang Mi-Ra
    • Journal of Korean Academy of Fundamentals of Nursing
    • /
    • v.13 no.1
    • /
    • pp.24-32
    • /
    • 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.

  • PDF

Analysis of Nursing Interventions Performed by Gynecological Nursing Unit Nurses Using the Nursing Interventions Classification (간호중재분류 (NIC)에 근거한 부인과 간호단위의 간호중재 분석)

  • Hong, Sung-Jung;Lee, Sung-Hee;Kim, Hwa-Sun
    • Women's Health Nursing
    • /
    • v.17 no.3
    • /
    • pp.275-284
    • /
    • 2011
  • Purpose: The purpose of this study was to identify nursing intervention performed by nurses on gynecological nursing units. Methods: The instrument in this study is based on the fifth edition of Nursing Interventions Classification (NIC) (2008). Data was collected by Electronic Medical record from August, 2010 to October, 2010 at one hospital and analyzed by using frequencies in the Microsoft Excel 2010 program. Results: Of a total of 82 NIC, domains of the nursing interventions showed higher percentages for physiological: basic (36.3%) and physiological: complex (34.5%). The classes of nursing interventions showed higher percentage for health system medication (12.1%), perioperative care (10.0%), and drug management (8.6%). The most frequently used top interventions were Discharge Planning. The thirty least used interventions was environmental management. Top thirty most frequently used interventions belonged to the domain of physiological: basic (37.9%), physiological: complex (31.1%), and behavioral (5.4%). Conclusion: These findings will help in the establishment of a standardized language for gynecological nursing units and enhance the quality of nursing care.

Method of The Interface Terminology Mapping based Free Text Medical Data (텍스트기반 임상데이터의 인터페이스 용어 매핑 방법)

  • Yoo, Done Sik;Bae, Inho
    • Journal of the Semiconductor & Display Technology
    • /
    • v.13 no.1
    • /
    • pp.97-99
    • /
    • 2014
  • Since 2010, issues for data sharing and data exchanging in hospital information systems have been emerged. In order to solve the issues, standards should be applied to develop the systems and there should be no ambiguities between terminologies in the systems. In this paper, the terminology mapping system for narrative clinical records was implemented. The term mapping precision was 83.4%. This system could help to upgrade the text based clinical system and it would be expected to support for high quality clinical services.

A Study on the Health Screening Solution by Using Electronic Medical Record (전자의무기록을 활용한 건강검진 솔루션에 관한 연구)

  • Lee, Hyo-Seung;Oh, Jae-Chul
    • The Journal of the Korea institute of electronic communication sciences
    • /
    • v.10 no.7
    • /
    • pp.825-830
    • /
    • 2015
  • The Electronic Medical Record(: EMR) is to store medical data not in the form of document, but in the data storage. Such EMR can not only solve various problems of document use such as storage/arrangement of and securing space for document, but also make it possible to provide customized-treatment based on large quantity of customer data, so that hospitals can reduce the management cost and also improve the work efficiency. Customers also can receive the great quality of medical service. Owing to such strengths, the EMR has been rapidly introduced and applied to many hospitals and clinics since 1990s. In case of the current health screening system, however, paper forms used for health screening is also stored, on top of EMR. There would be various reasons why it is stored in the form of document. While the EMR used in hospitals is comprised of a unit program performing medical record, the health screening system is comprised of a unit program performing logics related to health screening. For this reason, it might be unavoidable for the health screening system to store document forms. If the EMR function is applied to the health screening system, it is expected to be able to operate more efficient health screening solution.

Point-of-care Testing Device Interface in Hospital Information System Standard Connectivity - Using of case ASTM protocol of ABGA application POCT1-A2 - (현장형 임상검사장비와 병원정보시스템의 접속표준 - ASTM protocol을 사용하는 ABGA의 POCT1-A2적용사례 중심으로 -)

  • Kim, Seon-Chil
    • Korean Journal of Digital Imaging in Medicine
    • /
    • v.10 no.2
    • /
    • pp.33-37
    • /
    • 2008
  • To keep the online medical records available to anyone without constraint of time and space, introducing EMR (Electronic medical record), which is a clinical support management system. The purpose of this study is to develop interface standard of clinical test device. Integration and sharing of medical information is faced with enormous obstacles because medical organizations and associated companies are separately developing the interface. I hope that multi-function management system with workstation concept is operated to efficiently transmit clinical device result data based on this study. Transfer of precise medical result data available for decision making will improve quality of health care service.

  • PDF

A study of the Characteristics of Readmitted Patients in an University Hospital in Korea (재입원 환자의 특성연구)

  • Hong, Joon-Hyun
    • Quality Improvement in Health Care
    • /
    • v.2 no.2
    • /
    • pp.56-71
    • /
    • 1996
  • Background : Review of readmissions in health care facilities is necessary from the viewpoint of both economic concerns and quality considerations. To identify the characteristics, factors, and causes of multiple admissions in comparison with single admissions is essential for both providers and payers in order to assure quality care and efficient use of medical resources. Methods: All discharges from an university hospital in 1993 were analyzed, and the characteristics of multiple admissions were identified and were compared with those of single admissions by using the data bases of the discharge abstract and billing for reimbursement. Medical records of patients readmitted within 6 days after the previous discharge were reviewed to identify the reasons for such prompt readmission. Statistical analysis between groups of patients were performed by using SPSS. Result : The mean age was higher in multiple admissions than those of single admissions, and the average length of stay was longer in multiple admissions than in single admissions. The hospital cost per day is higher in single admissions while the cost per case is higher in multiple admissions. More than half of readmissions occurred within one month after the preceding discharges. Above 15% of the readmission within 6 days after the preceding discharges seemed to have close relationship with quality of care provided during the preceding hospitalization. The death rate of the patients readmitted within 6 days was the highest in comparison with multiple admissions and single admissions. Conclusion : Potential preventable readmissions should be reduced by identifying characteristics of multiple admissions, especially unplanned readmission, and by applying some interventions such as standard predischarge assessment or careful follow-up care after discharge for high risk readmission groups. As the results of these efforts, health care facilities could achieve quality improvement in medical care, and effective use of hospital resources.

  • PDF

PDA Transmission of Medical Images by CDMA (CDMA에 의한 의료영상의 PDA전송)

  • Lee, Myong-Ho;Lim, Jae-Dong;Ahn, Bung-Ju;Lee, Hwun-Jae;Lee, Sang-Bock
    • Journal of the Korean Society of Radiology
    • /
    • v.1 no.2
    • /
    • pp.13-22
    • /
    • 2007
  • The purpose of this study was to survey a development of the wireless transmission system of medical images for ubiquitous medicine. There have been many changes in medical equipments and medical record medical treatment and medical record within hospital and PACS(Picture Archiving Communication System) which is picture management system for patients can be typical cases. It is difficult to use these automated medical systems unless they are within hospital and in case of rapid image reading in the emergency cases or in absence of doctor, it is difficult to perform it immediately. The present study implemented an image transmission system using CDMA connection so that images in the server can be viewed at any time and in any place. Remote wireless diagnosis based on medical images using PDA is applicable to medical areas that require mobility, and the use of PDA can be an ideal alternative for point of care. The use of PDA enables prompt and accurate access to digital medical images, which in turn reduces medical accidents and improves the quality of medical services through high productivity and efficiency of medical practitioners' works. It also enables quick response to patients' demands and high-quality medical services and, consequently, patients' high satisfaction.

  • PDF

The Level of Job Satisfaction and Organizational Commitment of Medical Record Technicians (의무기록사의 직무만족도 및 조직몰입도)

  • Choei, Eun-Mi;Kim, Young-Hoon
    • Korea Journal of Hospital Management
    • /
    • v.8 no.3
    • /
    • pp.72-91
    • /
    • 2003
  • The purpose of this study is to investigate the recognition of health information managers, and to analyze the level of job satisfaction and organizational commitment of medical record technicians. The data for this study were collected through a self-administered survey with a structured questionnaire to 172 subjects from medical record technicians working in hospitals in Seoul and Gyeonggi Province as well as the faculty of medical schools across South Korea. In this analysis frequency, t-test, ANOVA, factor analysis and structural equation model were used. The main findings of this study are as follows: 1. As for recognition of the seven dimensions in the role of health information managers, the role as clinical data specialist received the most positive feedback, followed by document & repository managers, patient information coordinators, health information managers, data quality managers, security officers and research & decision support analyst. 2. The level of job satisfaction among medical information handlers and managers averaged 3.14. In terms of the factors in the work environment concerned with job satisfaction, being able to work independently and as team players reached the top among 6 factors with the average of 3.39, followed by professional position, salary & rewards, expectations for job performance and administration. 3. The average rate of organizational commitment stood at 3.09. Respondents tend to be focused on present tasks rather than future-oriented tasks. 4. The result of the analysis based on the relationship between recognition as health information managers, job satisfaction and organizational commitment found that all analysis are statistically meaningful. The more the respondents were aware of their roles as health information managers, the more they tended to be committed to their work and satisfied with their work. The more the respondents were committed to their work, the more satisfaction was seen. The effects of recognition as health information managers on organizational commitment measured 0.27 and for job satisfaction it was 0.17. The effects of organizational commitment on job satisfaction stood at 0.71. The feasibility of the model meets the standard at Chi-square value of 66.755 and the P value of 0.057. The Normed Fit Index (NFI) of 0.930 was in compliance with the standard for model feasibility and the squared multiple correlation coefficient of this model was 8% in organizational commitment and 60% in job satisfaction.

  • PDF