• Title/Summary/Keyword: quality score of record

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A Study on the Factors Related to the Quality of Medical Records - focused on physician's commitment - (의무기록의 질에 영향을 미치는 요인 분석 - 주치의사의 관심도를 중심으로 -)

  • Hong, Joon Hyun;Choi, Kwisook;Lee, Eun Mee
    • 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.

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A Study on Sasang Constitutional Characteristics of Atopic Dermatitis Patients Based on Atopic Dermatitis Personal Health Record (개인 건강 기록을 통한 아토피 피부염 환자의 사상체질 특성에 관한 연구)

  • Sung, Hyun-Kyung;Go, Ho-Yeon;Shin, Mi-Ran
    • Journal of Sasang Constitutional Medicine
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    • v.31 no.4
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    • pp.41-56
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    • 2019
  • Objective The purpose of this study is to analyze the daily life records of atopic dermatitis patients according to Sasang Constitution based on the data recorded using Personal Health Record (PHR) platform, and to find basic data for the Sasang Constitutional daily life management and prevention. Method Thirty patients with atopic dermatitis under 19 years old were included. The data recorded using PHR platform by the patient or the parents for 6 weeks and allergic blood tests were analyzed according to Sasang Constitution. Result As a result of analyzing the atopic dermatitis PHR related to Sasang Constitutional characteristics, there were no significant differences due to the small number of subjects. There were a tendency associated with the Sasang Constitutional characteristics in the emotional state, urine, stool and weakness score of five viscera. Allergic reactions tended to occur in those with higher weakness score of Viscera. There was a significant correlation between quality of life and SCORing Atopic Dermatitis(SCORAD) score. Conclusion This study can be considered as a primary study on items that tend to be associated with Sasang constitutional characteristics in patients with atopic dermatitis.

A Study on the Level of Medical Record Documentation and Agreement in the Information on the Patient's Past History (과거력 의무기록 정보의 기재정도 및 일치도 분석)

  • Seo, Jung-Sook;Yu, Seung-Hum;Oh, Hyohn-Joo;Kim, Yong-Oock
    • 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.

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Evaluation of Diet Quality of Children and Adolescents Based on Nutrient and Food Group Intake and Diet Quality Index-International (DQI-I) (삼척 지역 아동과 청소년의 영양소, 식품군별 섭취 및 DQI-I를 기준으로 한 식사의 질 평가)

  • Kim, Mi-Hyun;Bae, Yun-Jung
    • Korean Journal of Community Nutrition
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    • v.15 no.1
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    • pp.1-14
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    • 2010
  • It is suggested that evaluation of diet quality may be a great indicator of nutritional assessment. The aim of this study was to evaluate the diet quality of children and adolescents based on nutrient and food group intake and Diet Quality Index-International (DQI-I). This survey was conducted through questionnaires and diet record survey to 477 students (elementary school students; n = 131, middle school students; n = 136, and high school students; n = 210). The results showed that high school students were significantly more often to skip breakfast compared with the other groups. The middle and high school students consumed significantly higher intakes of food and energy compared to the elementary school students. Also the number of nutrients in Index of Nutritional Quality (INQ) < 1.0 of high school students were significantly higher than that of elementary and middle school students. The Korean's dietary diversity score (KDDS) of elementary school, middle school and high school students were 4.1, 4.4 and 4.3 respectively. The average DQI-I of elementary school, middle school and high school students were 66.7, 65.5, and 63.7, respectively and there was significant difference. Also, middle school students showed to have higher score in variety and adequacy category compared with the other groups, and elementary school students appeared to have higher score in moderation category. In conclusion, high school students appeared to have unhealthy dietary habits in terms of high frequency of skipping breakfast and lower INQ and DQI-I score compared to the elementary school and middle school students. Therefore, the proper dietary management should be needed for high school students.

A study for quality assurance of visiting nurses service of a public health center (보건소 방문 간호 사업의 질보장을 위한 연구)

  • Yun, Soon-Nyoung;Lee, In-Sook;Hyun, Hye-Jin;You, In-Ja;Kim, Jai-Nam;Bae, Jung-Hee
    • Research in Community and Public Health Nursing
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    • v.6 no.2
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    • pp.275-285
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    • 1995
  • The purpose of the study is to evaluate the visiting nurses service of a public health center. Data were collectd from the 36 clients who received services from a public health center. In terms of the process evaluation, the tool is composed 4 parts, 27 items such as assessment planning, implementation, and evaluation. It was measured through the health records by 2 peer review. In terms of the outcome evaluation, the level of client satisfaction was measured by self report or interview by 2 supervisor. The result were as follows: 1. 30% of 36 health records showed narsing process was not and out of them, nursing care plann including spectific activities were rarely established or unclear. 2. The lack of systematic data collection' showed and nursing diagnosis was not adressed in health records review. 3. Client satisfaction score was 32, 97, out of maximum score 36. 4. The lack of sufficent objective data, care plan, record of client's health status change, and evaluation was founded therefore quality assurance for visiting nurses service and in-service education are required and the development of standardized record system need.

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Development of an evaluation tool for the quality of nursing care in neurosurgical intensive care unit patients (신경외과 중환자 간호의 질평가 도구개발)

  • Kim, Nam-Young;Jang, Keum-Seong
    • Journal of Korean Academy of Nursing Administration
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    • v.7 no.2
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    • pp.285-300
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    • 2001
  • To meet standards for high quality of care and satisfied customers, an evaluation tool about nursing care is necessary. And, We need to evaluate our practice continuously for the improvement in quality and outcomes. This study was intended to develop an evaluation tool about nursing care in NSICU, and was progressed of 3 steps; development, content validity verification and reliability verification. Data were obtained and analysed from Feb. To April, 2000. Development process of the study was as follows A preliminary list was made item by item on the basis of clinical Experience, literature review and patients' record review. Then the standards, criteria and indicators of preliminary evaluation tool were set by 5 clinical nursing panel, and their content validity was reviewed by 27 ICU nurses. Finally, an evaluation tool was developed and verified the reliability at c-university hospital located in Kwang-Ju. The results of this was as follows 1) The evaluation tool of this study developed 8 standards, 39 criterias and 106 indicators. The standards were divided into two dimensions. One was process dimension which contained 4 standards(26 criteria), The other was outcome dimension which contained 4 standards(13 criteria). 2) the Average content validity of the tool was 3.39 at standards, 3.55 at criteria and 3.51 at indicators. 3) Interrater reliability of the tool is r=.7993(p<.001) & internal consistency reliability ${\alpha}$ is .6031 4) Scores of NSICU Patients who participated in this study were 57 at total mean score, 58 at process mean score and 56 at outcome mean score The evaluation tool developed in this study seems to be useful in evaluation nursing practice appropriately for the improvement of nursing care in NSICU. I hope that this evaluation tool can be used effectively in NSICU as an intervention for the improvement of quality control.

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Development of the Performance Measurement Model of Electronic Medical Record System - Focused on Balanced Score Card - (균형성과표를 활용한 전자의무기록시스템의 성과측정 모형개발)

  • Lee, Kyung Hee;Kim, Young Hoon;Boo, Yoo Kyung
    • Korea Journal of Hospital Management
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    • v.21 no.4
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    • pp.1-12
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    • 2016
  • The purpose of this study are suggest to performance measurement model of Electronic Medical Record(EMR) and Key Performance Index(KPI). For data collection, 665 questionnaires were distributed to medical record administrators and insurance reviewers at 31 hospitals, and 580 questionnaires were collected(collection rate: 87.2%). Regarding methodology, Critical Success Factor(CSF) and index of the information system were derived based on previous studies, and these were set as performance measurement factors of EMR system. The performance measurement factors were constructed by perspective using BSC, and analysis on causal relationship between factors was conducted. A model of causal relationship was established, and performance measurement model of EMR system was proposed through model validation. Analysis on causal relationship between performance management factors revealed that utility cognition of the learning & growth perspective factor had causal relationship with job efficiency(${\beta}=0.20$) and decision support(${\beta}=0.66$) of the internal process perspective factors, and security had causal relationship with system satisfaction(${\beta}=0.31$) of the customer perspective factor. System quality had causal relationship with job efficiency(${\beta}=0.66$) and decision support(${\beta}=0.76$) of the internal process perspective factors, all of which were statistically significant(P<0.01). Job efficiency of the internal process perspective had causal relationship with system satisfaction(${\beta}=0.43$), and decision support had causal relationship with decision support satisfaction(${\beta}=0.91$) and job satisfaction (${\beta}=0.74$), all of which were statistically significant(P<0.01). System satisfaction of the customer perspective had causal relationship with job satisfaction(${\beta}=0.12$), job satisfaction had causal relationship with cost reduction(${\beta}=0.53$) of the financial perspective, and decision support satisfaction had causal relationship with productivity improvement(${\beta}=0.40$)of the financial perspective(P<0.01). Also, cost reduction of the financial perspective had causal relationship with productivity improvement(${\beta}=0.37$), all which were statistically significant(P<0.05). Suitability index verification of the performance measurement model whose causal relationship was found to be statistically significant revealed that $X^2/df=2.875$, RMR=0.036, GFI=0.831, AGFI=0.810, CFI=0.887, NFI=0.838, IFI=0.888, RMSEA=0.057, PNFI=0.781, and PCFI=0.827, all of which were in suitable levels. In conclusion, the performance measurement indices of EMR system include utility cognition, security, and system quality of the learning & growth perspective, decision support and job efficiency of the internal process perspective, system satisfaction, decision support satisfaction, and job satisfaction of the customer perspective, and productivity improvement and cost reduction of the financial perspective. In this study, it is expected that the performance measurement indices and model of EMR system which are suggested by the author, will be a measurement tool available for system performance measurement of EMR system in medical institutions.

A Comparative Study on the Quality of Life of Korean and Chinese Women Who Are Employed and Married (한국과 중국 기혼취업여성의 주관적 삶의 질에 관한 비교연구)

  • An, Hua-Shan;Kim, Kyeong-Shin
    • Journal of Families and Better Life
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    • v.27 no.1
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    • pp.127-144
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    • 2009
  • This study examines the factors that influence the subjective quality of life for Korean, Chinese-Korean, and Chinese women who are both married and employed, and it offers suggestions based on this examination for how to improve these women's quality of life. In particular, we employ both empirical and comparative research to explore the causal relationship in these three groups of women between variables such as cultural orientations, life satisfactions and the perceived quality of life. For these objectives, 263 Korean women, 265 Chinese-Korean women and 280 Chinese women were surveyed. The research can be summarized as follows: First, when we consider subjective quality of life as the dependent variable and factors such as self-esteem, cultural inclination and life satisfactions as independent variables, we find that most of variables record relatively higher than middle score. Comparisons among the three groups find that every variable shows meaningful differences among the groups except for the non-economic reasons for employment. Second, in examining the relative influence of the different variables on the subjective quality of life, we observe that both job satisfaction and family-life satisfaction have a significant influence on the quality of life for women in all groups. For Korean and Chinese women, job satisfaction has a greater influence on the quality of life than family-life satisfaction.

Characteristics of Atopic Dermatitis Patients Based on Personal Health Records (PHR) according to Age and Sasang Constitution (연령과 사상체질에 따른 개인건강기록(PHR)에 기반한 아토피피부염 환자의 특성)

  • Oh, Jin-Ah;Sung, Hyun-Kyung;Go, Ho-Yeon;Shin, Mi-Ran
    • The Journal of Pediatrics of Korean Medicine
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    • v.35 no.1
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    • pp.63-75
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    • 2021
  • Objectives The purpose of this study is to identify the characteristics of atopic dermatitis patients based on the personal health records (PHR) according to age and Sasang Constitution, and to find basic data for daily life management using the personal health record. Methods We analyzed the characteristics of atopic dermatitis patients based on PHR (symptoms, emotional state, SCORAD Index, five viscera weakness questionnaire, etc.), and Sasang Constitution collected for 6 weeks in 34 patients (or guardians). Results Each item of the SCORAD Index score in children and adolescents showed that children and adolescents have significantly higher edema than adults. However, repeated measurement of the SCORAD Index showed a significant positive improvement over time regardless of age and constitution. In terms of the symptoms of atopic dermatitis, there was a significant correlation between age and swelling, quality of life and effusion, pruritus (itch) and sleep disturbance in relation to the general characteristics of the subject. In the five visceral weakness scores, adults had significantly higher spleen weakness, liver weakness, kidney weakness scores than in children and adolescents. All results showed a high tendency to have a high lung weakness score, which was more pronounced in children and adolescents. Conclusion This study is meaningful to confirm the correlation between SCORAD Index items related to the symptoms of atopic dermatitis, and to identify trends for specific items by ages and Sasang Constitution.

The Iron Status and Diet Quality of Pregnant Women during the First Five Months of Pregnancy (임신 전반기 여성의 철분 영양상태와 식사의 질)

  • 윤지숙;박정아;손숙미
    • Korean Journal of Community Nutrition
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    • v.8 no.6
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    • pp.803-813
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    • 2003
  • Literature suggests that iron deficiency anemia is prevalent among pregnant women all over the world. This study was designed to evaluate the iron status of pregnant women during the fist five months, with the intention of determining ways to reduce the prevalence of iron deficiency anemia among pregnant women in Korea. We collected dietary information and measured the biochemical status of iron in 171 pregnant women over 16 weeks of gestation (=16.7$\pm$2.34 week). Dietary intakes for 3 days were collected using the 24 hour recall and food record methods. The daily Fe intake was measured using the food frequency method. The Body Mass Index (BMI), calculated by using the pre-pregnancy weight and height, indicated that 31.3% of subjects were under-weight. We divided the subjects into normal and anemic group by using the serum ferritin levels. It appeared that the mean dietary intake of iron was 52.3% of the recommended level for pregnant women. The dietary quality evaluation showed that pregnant women ate only 58% of the recommended amount in the food groups of meat, fish, eggs, beans and milk and dairy products. The hematological indices showed that the mean Hemoglobin (Hb) was 11.9 g/dl, Hematocrit (Hct) was 35.1%, ferritin was 23.9 $ng/ml$, and transferrin was 297.3 ${\mu}g/dl$. The dietary intake of iron was significantly lower and the vitamin C intake was significantly higher in the anemic group. The pre-pregnancy BMI was significantly lower in the anemic group. Variables affecting iron intake were the Fe intake frequency index and the food group score. The Fe index showed significantly positive correlation with the pre-pregnancy food intake and the food group score. Hb showed a significantly positive correlation with the pre-pregnancy food intake. We concluded that strategies to improve iron status be implemented in the pre-pregnant stage so as to reduce the prevalence of iron deficiency and that we should stress on the importance of an adequate diet as well as the maintenance of a heathy weight.