• 제목/요약/키워드: record

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

  • 서정숙;유승흠;오현주;김용욱
    • 한국병원경영학회지
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    • 제13권1호
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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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회상법, 기록법 및 식품섭취빈도조사법을 이용한 노인의 영양소 섭취 수준의 비교 (Comparison of Dietary Intakes by 24-hr Dietary Recall, Dietary Record and Food Frequency Questionnaire among Elderly People)

  • 최미숙;한경희;박기순
    • Journal of Nutrition and Health
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    • 제34권6호
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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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ICT기술을 활용한 동영상 기록관리 및 이용의 활성화 방안 연구 (A Study on the Activation Method of ICT-Based Video Record Management and Utilization)

  • 이상헌;변선영;유현정;박춘원
    • 한국기록관리학회지
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    • 제18권2호
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    • pp.215-242
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    • 2018
  • 레코드 컨티뉴엄 이론은 전통적인 기록관리 이론인 생애주기이론의, 시간적 흐름을 기반으로 하는, 현용-준현용-비현용의 분절된 기록관리를 비판하며 호주에서 연구되기 시작하였다. 또한 시간적 공간적 제약이 없는 전자기록을 관리하는 새로운 패러다임으로 등장하여, 기록을 고정된 물리적 객체로만 인식하지 않고, 논리적, 개념적 개체로 인식하며, 기록을 둘러 싼 복합적이고 다차원적인 환경을 고려한 다원화된 기록관리를 주장하고 있다. 이러한 레코드 컨티뉴엄이론을 바탕으로 이론 연구자인 업 워드(Frank Upward)의 레코드 컨티뉴엄 도해(圖解, 개념도)의 4개의 축선과 차원에 현재의 ICT기술을 적용하고, 동영상 기록관리 및 이용을 지능화하여 전자기록시대에 적합한 동영상 기록관리 방법론을 현실화 해보고자 한다.

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

  • 김태수
    • 한국기록관리학회지
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    • 제2권1호
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    • pp.7-39
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    • 2002
  • 본 연구에서는 외국의 기록관리학 교육과정을 조사하여 검토하였다. 대상국가로는 미국, 중국, 프랑스, 일본이 포함되며 이들 자료를 통하여 국내 기록관리학의 영역과 교육수준을 수립하고자 시도하였다. 즉, 기록관리를 위한 전문인력의 교육목표, 일반지침, 영역별 교과과정을 제시하였다. 또한, 기록물 관리를 위한 전문인력제도에 대하여서도 살펴보았으며 현행 기록관리법에서 제시하는 기록물 관리를 위한 전문요원의 자격조건에 대한 개선안을 제시하였다.

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

  • 신영규
    • Clinical and Experimental Pediatrics
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    • 제51권9호
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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.

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

  • 류한조;김익한
    • 한국기록관리학회지
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    • 제9권1호
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    • pp.221-248
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    • 2009
  • 이 글은 기록을 이용한 재현 콘텐츠를 개발하는 절차모형을 제시하기 위해 작성되었다. 모든 기록은 본질적으로 대상을 재현할 수 있는 속성을 지니므로, 이러한 속성을 활용하여 재현 콘텐츠를 개발할 수 있다. 재현대상을 건축문화재로 선정한다면 건축문화재 가치와 기록을 분석하고, 이를 토대로 일정한 틀을 적용하여야 한다. 이글은 이러한 과정을 하나의 프로세스로 정리하여 제시하였다.

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

  • 최정환;이상일
    • 해양환경안전학회지
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    • 제20권4호
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    • pp.389-397
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    • 2014
  • 본 연구에서는 기름기록부의 정의 및 법적근거를 살펴보며, 우리나라 및 주요 해양국가의 기름기록부 허위기재에 대한 법령을 비교 고찰하여, 우리나라 기름기록부의 기록과 점검에 대한 실효성을 높이기 위한 법률적 제도적 방안을 제시함으로써 선박으로부터 발생하는 해양오염을 사전에 예방할 수 있는 개선책을 연구하고자 하였다. 본 연구결과에서 제시된 문제점 개선을 위한 방안으로서 첫째, 기름기록부의 각 항목별 기록사항에 대한 구체적 행정처분의 규정을 제정하여 해양오염 발생 후 단순 증거로서 효력을 가지는 기름기록부가 아닌 사전조사를 통한 엄격한 제재조치가 될 수 있도록 해야 할 것이다. 둘째, 항만국통제관의 기름기록부 허위기재에 대한 판단의 기준을 설정하여 통일된 규제가 될 수 있도록 해야 할 것이다. 셋째, 기름기록부 제I부 (C) Code 11. 유성잔류물 및 (D) Code 저장구역 빌지의 선외배출과 관련한 단순 기록 불일치 사항도 고의성여부를 포함시켜 엄격함을 유지시켜나가야 할 것이다. 또한 해양오염방지관리인의 기름기록부 기록사항에 대한 사전점검 역할을 강화하여 기름기록부의 기록사항의 중요성 인식을 제시함으로써 기름기록부의 실효성을 높이고자 한다.

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

  • 박성철
    • 무역상무연구
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    • 제19권
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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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전자의무기록의 충실성 검토를 통한 미비기록 개선 활동 (Improvement Activity for Promotion of Incomplete Medical Record through the Review of Electronic Medical Record Completeness)

  • 조윤정;김경숙;이향숙;이진영;김태민;김민순
    • 한국의료질향상학회지
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    • 제14권1호
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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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조선시대 전기의 포백척에 관한 연구(上) - 조선왕조실록을 중심으로 - (A Study on Pobeckchuck in the Former Period of Chosun Dynasty(First) - Focusing on the True Record of Chosun Dynasty -)

  • 이은경
    • 복식
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    • 제53권4호
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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.