• Title/Summary/Keyword: record

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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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Comparison of Dietary Intakes by 24-hr Dietary Recall, Dietary Record and Food Frequency Questionnaire among Elderly People (회상법, 기록법 및 식품섭취빈도조사법을 이용한 노인의 영양소 섭취 수준의 비교)

  • 최미숙;한경희;박기순
    • Journal of Nutrition and Health
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    • v.34 no.6
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    • pp.688-700
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    • 2001
  • Nutrient intakes estimated using a 24-hr recall, a dirt record and a food frequency questionnaire(FFQ) were compared in a group of ninety-four elderly people(21 males, 73 females) in Cheongju, a city in Chung-Buk province. Mean intakes for energy, protein, Ca, p, Na, K thiamin and niacin obtained from the diet record were higher than those from the 24-hr recall. Mean intakes for energy, protein, Ca, P, Na, K thiamin, niacin and vitamin C from the FFQ were higher than those obtained from the 24-hr recall or the diet record. Correlation coefficients between the nutrient intake values from the 24-hr recall and those from the diet record ranged from 0.84 to 0.95 and were significantly correlated(p < 0.001). About 80% of the subjects in the lowest quintile by the 24-hr recall were also in the lowest two quintiles by the diet record. While the percentage fallen into the opposite category ranged from 0% to 15%. For most nutrients, at least 65% of the subjects when classified by the 24-hr recall fell into the same quintile when classified by the diet record, and the mean kappa value was 0.7. About 52% of the subjects in the lowest category by the 24-hr recall fell into the lowest two categories by FFQ. The mean percentage of the subjects in the lowest quintile by the diet record or in the lowest two quintiles by the FFQ was 51%. For most nutrients, at least 24% of each of the subjects when classified by both the 24-hr recall and the diet record fell into the same category when classified by the FFQ. The kappa values between the 24-hr recall or the diet recall and the FFQ were 0.17. These data indicate that in elderly subjects the 24-hr recall can provide very similar information to that obtained from the diet record but the FFQ can not provide good information if the right FFQ method is not used for only elderly subjects.

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A Study on the Activation Method of ICT-Based Video Record Management and Utilization (ICT기술을 활용한 동영상 기록관리 및 이용의 활성화 방안 연구)

  • Lee, Sang hyuen;Byeon, Seon yeong;You, Hyeon jeong;Park, Choon won
    • Journal of Korean Society of Archives and Records Management
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    • v.18 no.2
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    • pp.215-242
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    • 2018
  • The record continuum theory is now being studied in Australia, wherein the segregated record management of current, semi-current, and past records based on the temporal flow of the life cycle theory are being critcized. In addition, it emerged as a new paradigm for electronic record management without time and spatial constraints. Moreover, it is recognized as a logical and conceptual entity rather than as a fixed physical object. It also makes it possible to record multiple records in consideration of the complex, multidimensional environment of records. Based on this record continuation theory, the current information and communications technology (ICT) is applied to the four axes and dimension of the record continuation diagram of theoretical researcher Frank Upward. The researchers aim to realize a video recording management method suitable for the electronic record age.

Education Courses and Professional policies in Record management (기록관리의 전문교육과정 및 전문인력제도)

  • Kim, Tae-Soo
    • Journal of Korean Society of Archives and Records Management
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    • v.2 no.1
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    • pp.7-39
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    • 2002
  • In this study, curriculums of Record Management in America, China, France, Japan were reviewed. Through this research, scope and education level of Record Management in Korea were considered, and education purpose, general guidance. curriculum of Record Management in Korea were suggested. Improved qualifications for Record Management Professionals were also suggested.

About the new edition of child and adolescent health record book ('소아청소년 건강수첩' 2008년 개정판에 대하여 -앞으로 모든 예방접종수첩을 제대로 된 '소아청소년 건강수첩'으로 바꿔줍시다-)

  • Shin, Young Kyoo
    • Clinical and Experimental Pediatrics
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    • v.51 no.9
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    • pp.907-910
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    • 2008
  • Recently we published new edition of 'child & Adolescent health record book' considering easy usability and introduction of new vaccines. This record book has essential and important contents for caring our children and adolescents. Currently many people use various vaccination record books with wrong and poor contents. We suggest the campaign that every pediatrician must give our well made record book to these people. This campaign can give their children an opportunity for proper vaccination and medical checkup. Ultimately through this campaign, the role and importance of pediatrician in the fields of vaccination and bring up children and adolescents will be recognized. We trust that the better record book can be made with continuous interest and active advice of all Korean Pediatric Society members about the contents and usability of this book.

A Study of the Developing Model of Record Contents: Focused on the Architecture Cultural Property Record (기록 콘텐츠 개발 모형에 관한 연구 - 건축 문화재 기록을 중심으로 -)

  • Ryu, Han-Jo;Kim, Ik-Han
    • Journal of Korean Society of Archives and Records Management
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    • v.9 no.1
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    • pp.221-248
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    • 2009
  • All records have attribute of representing the object, so archives should develop digital record exhibition to facilitate attribute that representing the object. If building cultural properties are chose as the represented object, it should be followed by analysis of nature values and record contents and applied to the suitable framework. Therefore, this study suggests the organized process of designing the framework which develops digital representing contents based on records.

A Study on the Way of Securing the Practical Effectiveness of Oil Record Book (기름기록부 실효성 확보에 관한 연구)

  • Choi, Jung-Hwan;Lee, Sang-Il
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.20 no.4
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    • pp.389-397
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    • 2014
  • The purpose of this thesis is studying for a legal basis and definition of Oil Record Book. In the thesis, comparing with the laws related to punishment for false entry of Oil Record Book of the maritime countries and korea Act. Studying the improvement marine pollutants from ships by suggesting legal and institutional proposal which are able to make themselves increase effectiveness for recording and inspection of Oil Record Book. Suggest the solution of the problems raised in this thesis, First, The Oil Record Book should not be the evidence which is having the effectiveness simply after the accident of marine pollution, but take sanction on pre-inspection of Oil Record Book as establish the concrete administrative punishment for each contents-based record of Oil Record Book. Second, It should set up of judgement criteria of false entry of Oil Record Book by port state control officer. Third, It should strengthen the legal effectiveness of Oil Record Book contents such as Code(c) ; oil residue, Code(d); relating to bilge discharge by including premeditation for false entry of Oil Record Book. Also, The enhancement of role for marine pollution prevention manager raise the effectiveness of Oil Record Book as recognizing the importance of Oil Record Book.

A Study on the Electronic Trade and eUCP (전자무역과 eUCP에 관한 연구)

  • Park, Sung-Chul
    • THE INTERNATIONAL COMMERCE & LAW REVIEW
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    • v.19
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    • pp.119-138
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    • 2003
  • ICC(International Chamber of Commerce) developed new rule on the presentation of electronic record in L/C transactions. This rule named as the e-UCP. The gists of this article are on the application of e-UCP in practice and it's some problems. The e-UCP is the supplement of current exisiting UCP but is superior to UCP under some circumstances. The e-UCP is only apply to the presentation of electronic record regardless of type of L/C(for example, traditional paper L/C or electronic L/C). The presentation of electronic record has some problems which has not seen in the presentation of paper document. These peblems are Time, Place of presentation, and format of electronic record and so on. The e-UCP provided on the basis of these problems. However, the e-UCP has some obscure provisions on the examination of electronic record and the corruption of electronic record. Who is responsible for the corruption of electronic record by the virus on the system of bank ? The current e-UCP is not clear on this matter. We have to note followings in case of presenting the documents electronically and applying the e-UCP. First, Beneficiary has additional duty to notice of completion of presentation. Second, It will be increasing the clean NEGO through prompt feedback of the descrepancy at the presenting time. Third, It is no use of L/G(Letter of Guarantee).

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Improvement Activity for Promotion of Incomplete Medical Record through the Review of Electronic Medical Record Completeness (전자의무기록의 충실성 검토를 통한 미비기록 개선 활동)

  • Cho, Yun-Jung;Kim, Kyung-Sook;Lee, Hyang-Sook;Lee, Jin-Young;Kim, Tae-Min;Kim, Min-Soon
    • Quality Improvement in Health Care
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    • v.14 no.1
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    • pp.69-74
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    • 2008
  • 문제: 전자의무기록(EMR) 시행 후 의무기록 정리율의 저하와 질적인 측면에서의 충실성과 정확성에 대한 문제점이 제기되었다. 목적: 전자의무기록의 정리율과 충실성 검토를 통하여 문제점을 파악하고 개선점 찾아 의무기록 정리율을 향상시키고 충실성을 높이고자 하였다. 의료기관: 서울시에 소재한 대학병원 의무기록과 질 향상 활동: 전자의무기록의 문제점을 개선하기 위하여 사용자 편의를 위한 EMR 프로그램 수정 및 보완, 진단 수술 관련 작업, 업무개선, 교육, 홍보 등의 활동을 실시하였다. 개선효과: 의무기록 정리율, 전자인증미비, 경과기록 기재일수, 퇴원요약 주진단 적합률, 기록지별 필수항목 기재율, 충실성에서 향상이 이루어졌다.

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A Study on Pobeckchuck in the Former Period of Chosun Dynasty(First) - Focusing on the True Record of Chosun Dynasty - (조선시대 전기의 포백척에 관한 연구(上) - 조선왕조실록을 중심으로 -)

  • 이은경
    • Journal of the Korean Society of Costume
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    • v.53 no.4
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    • pp.87-99
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    • 2003
  • The measurement in ruling period of King Sejong in Chosun Dynasty remained unchanged compared with that of Goyeo Dynasty. But Hwangjongchuck, the basis of measurement was amended in the 7th year in ruling period of King Sejong, Juchuck, Youngchochuck, Cholegichuck in the 12th, and Pobeckchuck in the 13th. The record of Pobeckchuck first appeared in the true record of Chosun Dynasty in the 4th year in ruling period of Sejong, and first record on the amendment of the Pobeckchuck was found in the 13th year in his ruling period. The presentation of the comparison of Pobeckchuck with Cholegichuck in volume 128 of true record of Sejong makes help the estimation of the length of Pobeckchuck. To calculate one Chuck of Pobeckchuck with this measurement comes to 44.75cm in present measurement, and the length at this time had remained unchanged to Yeonsangun period. Important fact which was newly found in the true record of Chosun Dynasty was that Pobeckchuck had been used for diverse purposes. Pobeckchuck was used to measure width, length and thickness in manufacturing wardrobe. and also to measure cloth decorating wardrobe. This is the first record(4th year of reign of Sejong) showing that Pobeckchuck was first used to measure cloth in Chosun Dynasty The record shows that Pobeckchuck was also used to measure the length of circumference of castle for its construction. to measure distances between people, the length of hook of wooden handle, and the height of man.