• Title/Summary/Keyword: resident record group

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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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The Beginning of Decentralization: Seongbuk Village Archive (자치분권의 시작, 성북마을아카이브)

  • Kang, Sungbong
    • Journal of Korean Society of Archives and Records Management
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    • v.22 no.1
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    • pp.237-243
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    • 2022
  • Seongbuk Village Archive is a village archive built by Seongbuk-gu Office and Seongbuk Cultural Center to contain the uniqueness and specificity of the region. It is a community archive that preserves the records of the community and a digital archive that builds a database through the digitalization of source data. The management system and home page were established through annual and step-by-step promotion through public-private governance. Seongbuk Village Archive's system is designed to facilitate data accumulation and connection between individual records based on the advanced village record standard classification system. Based on this, Seongbuk Cultural Center tried to produce convergence cultural content by linking records online and off-line. In addition, the composition of items displayed on the website has been diversified to not only preserve records but also produce and utilize content. It is a structure created after contemplating how to show the creation and existence of Seongbuk's historical and cultural resources to users in context. In addition, a richer archive platform was built through various curations and activities of the resident record group.

A Study on the Difference of Influential Group in Putting on Clothing and delinguency for Students (중고등학생의 비행정도와 의복착용시 영향집단의 차이에 관한 연구)

  • 홍선옥
    • Journal of the Korea Fashion and Costume Design Association
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    • v.4 no.2
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    • pp.47-67
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    • 2002
  • The purpose of this study was to investigate the differences of Middle and High School Students' influential groups in putting on clothing according to their delinquency and demographic variables. My subject was 1050 middle and high school boys and girls who are resident in Seoul; sample groups were selected, considered their resident area, gender and the kind of school. The results are as follows: 1. The exemplary group was most regarded the opinion and evaluation of teacher, father and mother and followed the clothing of teacher. Compared with the exemplary group, the delinquent group was most regarded the opinion and evaluation of other and same sex friend and tended to follow their clothing style. Besides, the delinquent and middle groups were most regarded the opinion and evaluation of seniors and tended to follow their clothing style. The mass media star was most modelled by delinquent group, following by middle and exemplary groups. 2. Schoolgirls were more regarded the opinion and evaluation of same sex friend and senior and were more remarkable to follow the clothing style of their parent, friend, senior or mass media star than schoolboys. The students who did well at school more were regarded the evaluation of father, mother and same sex friend than those who did commonly or poorly. As for the exemplary group, the poorer a student did at school, the more he/she tended to follow the clothing style of mass media star, but on the contrary, as for the delinquent group, all students tended to follow the clothing style of mass media star regardless of their academic record. And there was no significant difference according to social status in important others and model group.

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Study of Medical Carein Health Subcenter (보건지소(保健支所) 진료활동(診療活動)에 관(關)한 연구(硏究))

  • Kim, Moon-Shik;Kim, Han-Joong;Kim, Young-Key;Kim, Il-Soon
    • Journal of Preventive Medicine and Public Health
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    • v.9 no.1
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    • pp.109-116
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    • 1976
  • Reorganization of myun health care service is one of the main issues in health care delivery in rural Korea. The fundamenta, concept of the role and function of the myun health subcenter is that it is the basic unit of rural health care service and is to provide comprehensive health care service through the integration of curative and preventive services. The aim of this study is to analyze the patterns of curative activities in the myun health subcenter in terms of the most prevalent types of diseases, necessary diagnostic methods and required equipment, types of treatment, necessary drugs and materials, and finally the cost of curative services. The population on which this study was done was the 1596 patients who visited the two myun health subcenters (Sunwon Myun and Naega Myun) in Kang Wha County, the area of the Yonsei University Community Health Teaching Project, during period from May 1, 1975 to June 10, 1976. For the patient's record in the clinic, problem oriented medical records were used. Decisions regarding the disease classification, the diagnostic methods used and selection of the most appropriate and adequate medical treatment were made by a group of three experienced physicians after reviewing the medical records which had been written by public physicians who were treating patients in the study area. The records were reviewed by resident staff members of the Department of Preventive Medicine, of Yonsei University College of Medicine. A brief summary of results of the study is as follow: 1. 29.9% of the patients who visited the clinics were ages between 0-4. No sex difference was observed among patients less than 20 years of age. However, among patients over 20 years old, females predominated. Thus it is evident that the majority of patients were either children or mothers and grandmothers. 2. The distance from the individual villages to the myun health subcenter was one of important factors in determining the ratio of clinic visits. However, other factors such as the activities of the health workers also affected the rates substantially. 3. The most common 25 diseases comprised 90.2% of all the diseases recorded. Acute respiratory infection (25.5%), Skin (12.7%) , diarrheal diseases (6.8%), neuralgia and back pain (4.9%) and. all other injuries (3.9%) were the five most common diseases. 4. Of all the diseases diagnosed and treated, 9.2% required simple laboratory tests for diagnosis, 6.5% required X-ray examination, and altogether 13.6% required either laboratory test or X-ray examination. 5. Treatment and management of 42.0% of the cases could be accomplished with simple, inexpensive drugs, 12.8% required the use of more expensive drugs (mostly antibiotics) and injections were required in 19.7% of the cases. Minor surgery and referral were necessary in 5% of the cases. 6. The cost for diagnosis and treatment was estimated with a standard which was set by general concensus. The average cost of diagnosis was 144 per case and the cost of treatment was 726 per case, The Total average cost per visit was 870.

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