• 한국기록관리학회지
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• 제9권1호
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• pp.77-98
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• 2009

본 연구는 '역대 대통령 웹기록 서비스'에 대한 이용자들의 만족도를 조사하여 이용 만족도에 영향을 미치는 요인을 분석하고, 검증과정에서 나타난 웹기록 서비스의 문제점 지적 및 개선 방안 모색을 목적으로 한다. 이용자 만족도를 측정하기 위해서 정보품질, 서비스품질, 시스템품질, 이용자만족의 네 가지 기본적인 차원과 이용자충성도와 이용자불평의 두 가지 부가적인 차원으로 구성된 정보시스템 평가 모형을 사용하였다. 분석결과 정보품질과 시스템품질 만족도가 각각 이용자의 전반적인 만족도에 통계적으로 유의한 영향을 미치는 것으로 나타났고, 이용자들의 계속적인 이용과 관련하여서는 정보품질과 서비스품질, 이용만족도가 유의한 영향을 미치는 것으로 나타났다.

• 한국의료질향상학회지
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• 제7권1호
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• pp.106-116
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• 2000

Background : Severance Hospital is an university hospital which has 1,580 beds. A LAN system was installed in the Medical Record Department in 1992 and discharge abstract data have been added to the discharge abstract database(DB) The previous work flow in the Medical Record Department had 5 levels: 1) chart collection from wards, 2) assembling, 3) abstracting data from medical record on worksheet by 2 RRAs, 4) checking deficiencies and coding diagnosis and procedures by 4 RRAs, 5) inputting the data into the discharge abstract data base by 1 RRA. The average processing time took 19.3 days from the patient discharge date. It had the production of monthly statistical report delayed. Besides, it caused the users in the hospital to complain. Methods : A CQI team was organized to find a way to shorten the processing time less than 10 days. The team identified the factors making the processing time long and integrated three levels from the 3rd level into one. Each of 7 RRAs performed the integrated level on her workstation instead of taking one of three separate levels. The comparison of processing time before and after the changes was made with 3'846 discharges of April, 1999 and 4,189 discharges of August, 1999. Results : The average processing time was shortened from 19.3 days to 8.7 days. Especially the integrated level took only 3.6 days, compared with 12.3 days before the change. The percentage of finishing up the whole processing within 10 days from discharge was increased up to 77.6%, which was 2.4% before the integration. The prevalence of error in data input was not increased in the new method. Conclusions : The integrated processing method has the following advantages: 1) the expedition of production of monthly statistical report, 2) the increase of utilizing rate of dischare abstract data by Billing Dept, Emergency Room, QI Dept., etc., 3) the improvement of intradepartmental work follow, 4) the enhancement of medical record quality by checking the deficiencies earlier than before.

• 품질경영학회지
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• 제47권4호
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• pp.911-926
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• 2019

Purpose: In an infinite market competition, companies are adopting management systems to gain a competitive advantage. The expectancy effect of the management system is management performance improvement and accurate measurements. These can be made through quality records with integrity and maintainability. This paper examines the operation of records management standards, which are records, storage and management standards for quality records to understand the needs of records management standards and empathize with their needs. Methods: This paper examines PEC's (Pields Engineering Co., Ltd.) specific processes and standards for integrating individual management systems and establishing records management standards. We also look at the specific features of the Search Tool and Document Storage Management Standards that support records management standards. Results: The integration process of PEC's individual management system consists of five steps. A PDCA-based process was established to erode the confusion and inefficiencies caused by overlap between individual management systems. Also, by accurately grasping corporate competence, PEC established a record management standard suitable for the characteristics of the company. PEC's records management standards are used as a useful standard for organizing quality records, and have an impact on management performance improvement. Conclusion: PEC's records management standards enable the verification of quality performance rates and performance measures. Companies can implement appropriate quality improvement strategies based on the numbers identified by introducing records management standards. Companies can succeed in improving management performance when operating quality management that combines performance measurement techniques and records management standards.

• 한국병원경영학회지
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• 제15권1호
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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.

• 한국의료질향상학회지
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• 제6권1_2호
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• pp.80-91
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• 1999

Background : With the CQI concepts, which emphasize doing the right things right the first time, we tried to enhance the timely completion of medical records by changing the review process from retrospective method to concurrent one. Methods : Against the current retrospective QA activity, Medical record administrator did the concurrent QA of the inpatient medical records with the deficiency sheets. One general surgery ward was chosen as a trial one. The deficiency rate of the medical records of the discharged patients was compared before and after the enforcement of the system. Job analysis of the medical record departments was done about four tertiary care hospitals located in Seoul to estimate the cost and the time consumed by current system. Results : There was a little improvement in the completion rate of the medical records after the trial. The new system was effective. And job analysis showed that much money and time were wasted by current retrospective feedback system. Conclusion : Though the result was not so satisfactory, it should be considered that this test was a voluntary one and the interns and residents were not forced to complete the medical records during this trial period. If there be any strong motivation to complete the medical record in time, this system is sure to be succeed. As the DRG system requires the concurrent review of the medical records to confirm severity of the patient's illness and to assure the timely discharge, it is desirable to enforce this method with the DRG system together. DRG coding and reducing deficiency rate of the medical records can be accomplished simultaneously.

• 한국의료질향상학회지
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• 제5권2호
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• pp.216-223
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• 1998

We surveyed the discordance rate of principal diagnosis made at emergency room(ER) & made at ward on discharge of the patients. Subjects were four hundred eighty cases who came to the ER of one third-line hospital from January 1, 1998 to January 31, 1998. The discordance rate was higher in patients admitted to medical department(8.2%) than surgical department(1.5%). If the patients were transferred to other department during hospital stay, discordance rate increased from 3.3% to 6.3%. In conclusion, discordance rate of principal diagnosis made at ER and made at ward was higher in patients with complicated problems. Medical record department should keep these findings in mind if it has a plan to support the management of ER record.

• 대한치과보철학회지
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• 제34권3호
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• pp.611-619
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• 1996

The purpose of this study was to evaluate the fitness of 4 kinds of resin record base materials. The record base materials used on the edentulous cast in this study were Triad VLC resin (Dentsply International Inc., U.S.A.), custom tray resin (Kerr Ltd., U.S.A.), heat-cure resin (Dentimex Co., Holland), and self-cure resin (Dentimex Co., Holland). The gap width between record base and cast were measured in the ridge crest and midpalatal area with microhardness tester. The results obtained were as follows : 1. Among the 4 kinds of record base, heat-cure Vertex fitted best on the cast. Triad and Fomatray fitted better than self-cure Vertex. Self-cure Vertex had the poorest fit. 2. The quality of the fit of the record base varied at different locations on the cast. The record base fit better in the ridge crest than midpalatal area. 3. In the midpalatal area, there's no significant difference in the fit of Fomatray, Triad and heat-cure Vertex. They all fit better than self-cure Vertex. 4. In the ridge crest, heat-cure Vertex fit better than any other record base.

• 한국의료질향상학회지
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• 제9권2호
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• pp.176-197
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• 2002

Backgound : This study is to suggest the standardized format of the clinical sheets and the standardized items of every clinical sheet. The standardization of the medical records will increase the faithfullnes of the contents in them and it will contribute to construct the good health information system. Method : From Jan. 1st. 2001 to March 31st 2001, we gathered as many paper clinical sheets as possible by every class of institutions to review the faithfulness of the clinical contents in them. Clinical sheets of 9 tertiary care hospitals, 6 general hospitals and 56 clinics were gathered. Two experienced medical record administrators reviewed them. The review focus was to check whether the items recommend by the hospital standardization review criteria and hospital service evaluation organization were appeared in the clinical sheets and whether the contents of every item were written. Results : Tertiary care hospitals; In case of administrative data, the contents were filled well if the items were fixed. The clinical data like C.C, history,physical examiniation were filled well, but if the items were not fixed, some items were omitted. The result is that more items are to be filled if they are fixed. General hospitals Administrative data were filled more than 50%. Final diagnosis was filled about 66.7%.But other clinical data were not filled well and not many clinical related items were appeared in the sheets.In the legal point of view, the reason for visiting hosptals or the right diagnosis, patient condition at discharge could not be confirmed well.In surgery cases, surgical procedures could not be confirmed well as many surgical related information(surgery time, fluids and blood, number of sponges, biopsy, etc) were omitted. Clinics More than 70% administrative data were filled and fixed as items. Among the clinical related data, laboratory result was the most credible data. But without the right diagnosis, drug orders were given and doctors' written signatures were not appeared over 96.4%. So the clinical sheets cannot be used as a legal document. Conculusion : There was a tendency that the contents were filled well if the items were fixed in the documents, We also suggest a clinical check list to review the completeness and faithfulness of the clinical sheets. If many hospitals use the suggested clincal check list and if they make the necessary items fixed in the clinical sheets, the quality of the medical record will increase dramatically.

• 한국의료질향상학회지
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• 제10권2호
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• pp.144-153
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• 2003

1) Background: The hospitals of modem society, like any other business entities, have to constantly strive to secure their survival from aggressive changes and competition outside. In this unstable environment, effective leadership is one of the most effective strategies for securing organization's growth as well as stability. This study investigated types of leadership (transformational or transactional) that is dominant in medical record departments and compared it's effects on organizational commitment and job satisfaction of their organizational members by types. 2) Method: A questionnaire was developed and mailed to all medical record administrators working at general hospitals throughout the country except department directors (N=450). Of these, 150 useable questionnaires were returned and analyzed by t-test, multiple regression analysis using SPSS. 3) Results: The organizational commitment and job satisfaction were a little bit higher than moderate level, and that of leadership perceived by medical record administrators was also in moderate level throughout types. Significant characteristics (positively) related to organizational commitment and job satisfaction by univariate analysis were marital status (married), position (middle management) and both type of leadership. However transformational leadership was the only significant factor in leadership styles after considering all the factors related to organizational commitment and job satisfaction together by multivariate analysis. 4) Conclusion: The average organizational commitment and job satisfaction of medical record administrators was just in moderate level. Efforts should be made to increase them by improving leadership capacity of medical record directors, primarily by using transformational leadership approach.

• 한국의료질향상학회지
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• 제10권2호
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• pp.204-215
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• 2003

Background : ICD-10 Classification, which is used domestically as well as internationally, has limited use in the clinical practice since it is developed for at disease statistics and epidemiology. Therefore, the purposes of this study were to improve the quality of diagnosis by constructing a new disease classification based on the diagnoses doctors currently make in the clinical setting and connecting this classification with OCS and EMR, and to meet the demands of doctors for high quality medical study data in medical research. Methods : The specialists in each ophthalmic subfield collected clinical diagnoses and abbreviations based on the ophthalmology textbooks and confirmed the classifications. Total number of clinical diagnoses collected was totaled 672, for which ideal diagnoses had been selected and a new model of disease classification model in connection with ICD-10 was constructed. The constructed classification of clinical diagnoses consisted of six steps: the first step was the classification by ophthalmic subspecialty field; the second to fifth steps were the detailed classification by each specialty field; the sixth step was the classification by site. Results : After introducing the new disease classification, research on the use and a pre-post comparison was conducted. The result from the research on the use of the clinical diagnoses in inpatient and outpatient care has shown a gradually increasing tendency. From the pre-post comparison of EMR discharge summary diagnoses, the result demonstrated that the diagnosis was stated correctly and in detail. Since the diagnosis was stated correctly, code classification became correct as well, which makes it possible to construct high quality medical DB. Conclusion : This construction of clinical diagnoses provides the medical team with high quality medical information. It is also expected to increase the accuracy and efficiency of service in the department of medical record and department of insurance investigation. In the future, if hospitals wish to construct a classification of clinical diagnosis and a standard proposal of clinical diagnosis is presented by a medical society, the standardization of diagnosis seems to be possible.