• 제목/요약/키워드: standardization diagnosis

검색결과 169건 처리시간 0.026초

의료기관 종별 의무기록 중요서식 항목별 작성 실태 및 의무기록 완결점검표 분석 (A Study on Medical Laws and External Evaluation Criteria with Reference to the Essential Forms consisting Medical Records and to the Items for Each Medical Record)

  • 서순원;김광환;황용화;강선희;강진경;조우현;홍준현;부유경;이현실
    • 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.

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임상진단명에 따른 질병분류체계 구축모형 개발 - 안과를 대상으로 - (Development of Construction Model of Disease Classification on Clinical Diagnosis in Ophthalmology)

  • 서진숙;신희영;기창원
    • 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.

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한의 정보 표준화를 위한 공통 임상 기록 서식 개발 연구 (A Development Study of Common Clinical Document Forms for Traditional Korean Medicine Information Standardization)

  • 문진석;김정철;박세욱;고호연;김보영;강병갑;강경원;최선미
    • 대한한의학회지
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    • 제30권1호
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    • pp.40-50
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    • 2009
  • Objectives: The clinical document forms, a format for collecting clinical data, is the most fundamental object of standardization. Doctors must have a mutual understanding of the clinical chart. Methods: Clinical document forms were developed by investigating existing conditions in hospitals and conducting demand surveys, doing literature research, and seeking expert advice for the improvement of version 1.0. In addition, an organization of a network of 19 Oriental medical doctors and nurses, 190 patients, and users of collected and assessed data was formed to come up with version 2.0. Results: The overall format was divided into different portions that the patient, nurse, and doctor must fill out, respectively. The patient's section consists of demographic data, lifestyle details, history, and symptoms. The data to be supplied by the nurse include the patient's vital signs and anthropometric parameters. As for the doctors, they are to supply data regarding the patient's palpitation, the detailed symptoms of the patient's head, ophthalmological and otorhinolaryngological symptoms (mouth), respiration, circulatory organ and chest conditions, digestive-organ conditions (thirst), neuropsychiatric conditions, reproductive system, musculoskeletal system, skin (depilation), etc. Conclusions: Common clinical chart development is the prior question to Traditional Korean Medicine standardization. A web-based clinical document format should be developed to support diagnosis and treatment, and furthermore EMR (electronic medical record system) and EHR (electronic health record) developed. Clinical information could be shared through a network of medical institutions and be useful Traditional Korean Medicine for evidence-based medicine.

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중풍진단(中風診斷)의 표준화방안(標準化方案) 연구(硏究) (A Study on the Standardization In Diagnostic Criteria on Jung-Pung (中風))

  • 심현기;박세기;김동우;전찬용;한양희;박종영
    • 대한한방내과학회지
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    • 제18권2호
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    • pp.332-357
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    • 1997
  • The purpose of study is for the defining the diagnostic criteria of Jung-Pung (中風) which are confused or unclear partially or Oriental Medicine. The results were obstained as follows ; 1. The Diagnosis of Jung-Pung (中風) can be accomplished by the name of disease, symptomatic classification, Byun-Jeung (辨證), stage, assessment of neurological deficit. 2. The various expressive way on the names of Jung-Pung (中風) can be unified as Jung-Pung (中風). 3. The symptomatic classification of Jung-Pung (中風) can be Jung-Kyung-Rak (中經絡) and Jung-Jang-Bu (中臟腑) by unconsciousness. 4. The subclassification of Jung-Kyung-Rak(中經絡) is Kanyangpokhang Punghwa sangyo (肝陽暴亢 風火上擾證), PungDamErHyul BiJoMaecRak (風痰瘀血 痺阻脈絡證), DamYeolBusil PoongDamSangYo (痰熱腑實 風痰上擾證), KiHerhyulEr (氣虛血瘀證), YeumHer PungDong (陰虛風動證) and Jung-Jang-Bu (中臟腑) is PungHwa SangYo CheongGeu (風火上擾淸竅證), DamSeupMongSac ShimSin (痰濕蒙塞心神證), DamYeolNaeFe ShimGeu (痰熱內閉心竅證), WonKiFaeTal ShimSinChakRan(元氣敗脫心神錯亂證) 5. The classification of stages can be divided as stroke stage, convalescent stage, complicated deficit stage. 6. In Oriental Medicine there were few assessment methods of neurological deficit. Therefore we need to develop new assessment system or modification of Western Medicine. The Standardization in the diagnosis of Jung-Pung (中風) has not been well established, even though we had have many clinical experiences. So it is necessary to make a accurate diagnosis that can be done by multiple diagnostic assessment. Therefore the accurate diagnosis of Jung-Pung (中風) can be done by 5 factors, they are the name of diagnosis, symptomatic classification, Byun-Jeung (辨證), stage, the assessment of neurological dificit. And it can be applied in the planning of treatment.

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알레르기 피부시험 (Allergic skin test)

  • 손병관;임대현
    • Clinical and Experimental Pediatrics
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    • 제50권5호
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    • pp.409-415
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    • 2007
  • Allergy skin prick test and intradermal test represent one of the major tools in the diagnosis of IgE-mediated diseases like as atopic asthma, allergic rhinitis, atopic dermatitis, food and drug allergy, and insect bite when properly performed. Skin tests are of particular importance in fields such as allergen standardization, pharmacology, and epidemiology. Even if skin tests seem easy to perform, adequate and proper interpretation requires well-trained physicians who can recognize the numerous factors that may modify the results of skin tests.

경항통(頸項痛)의 변증(辨證)에 관한 문헌고찰(文獻考察) (The Study on the Books of Oriental Medicine Which Deal with Variation in Diagnosis on the Neck and Nuchal Pain)

  • 황종순;김경호
    • Journal of Acupuncture Research
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    • 제24권2호
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    • pp.169-185
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    • 2007
  • Objectives : The studies on variation in diagnosis on the neck and nuchal pain has not been done thoroughly as we can use it in clinical practice of these days. For this reason, I examined the variation in diagnosis mentioned in the classics of Oriental Medicine as the preceding study on standardization of variation in diagnosis on neck and nuchal pain. Methods : I gathered the twenty kinds of classics of Oriental Medicine that were computerized, the textbooks on Oriental Medicine which are being used these days, and the theses on current clinical research. After gathering these data, I analyzed these according to the variation in diagnosis. Results : The classics of Oriental Medicine on the neck and nuchal pain mentioned very much about the neck and nuchal pain occurred by the pathogenic factor of Wind, Cold, and Dampness, disharmony created by deficiency of Liver and Kidney, and pathogenic state of Meridians of Taiyang. According to the texts of these days, the differentiation of syndromes can be divided into four kinds of items such as Wind-Cold pathogen, Wind-Dampness pathogen, Phelgm-Heat, and disharmony between Qi and Blood. The theses of these days rarely mentioned about variation in diagnosis on the neck and nuchal pain. Conclusions : The differentiation of syndromes on the neck and nuchal pain can be divided into four kinds items as affection by exopathogen like Wind, Cold, Dampness, Heat, and so on, stagnation of Qi and the coagulation blood, deficient syndrome of Liver and Kidney, and deficient syndrome of Qi and Blood.

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국제 표준화를 위한 화재이후의 유지관리 시스템 개발 (The Standardized Methods for Improvement of Maintenance Deterioration caused by Fire damage)

  • 권영진;구인혁;김동은;서동구
    • 한국건축시공학회:학술대회논문집
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    • 한국건축시공학회 2013년도 추계 학술논문 발표대회
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    • pp.230-231
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    • 2013
  • A fire outbreak in a reinforcement concrete structure looses the organism by different contraction and expansion of hardened cement pastes and aggregate, and causes cracks by thermal stress, leading to the deterioration of the durability. So, concrete reinforcement structure is damaged partial or whole structure system. Therefore accurate diagnosis of deterioration is needed based on mechanism of fire deterioration in general concrete structures. Fundamental information and data on the properties of concrete exposed to high temperature are necessary for accurate diagnosis of deterioration. In this study, consider case of investigation methods and repair work in fire damaged structure concrete.

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화재피해 콘크리트의 유지관리 및 시공성능 향상을 위한 표준화방안 (The Standardized Methods for Improvement of Maintenance and Performance Construction of Deterioration caused by Fire damage)

  • 서동구;김동은;김봉찬;권영진
    • 한국건축시공학회:학술대회논문집
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    • 한국건축시공학회 2013년도 춘계 학술논문 발표대회
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    • pp.16-18
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    • 2013
  • A fire outbreak in a reinforcement concrete structure looses the organism by different contraction and expansion of hardened cement pastes and aggregate, and causes cracks by thermal stress, leading to the deterioration of the durability. So, concrete reinforcement structure is damaged partial or whole structure system. Therefore accurate diagnosis of deterioration is needed based on mechanism of fire deterioration in general concrete structures. Fundamental information and data on the properties of concrete exposed to high temperature are necessary for accurate diagnosis of deterioration. In this study, consider case of investigation methods and repair work in fire damaged structure concrete.

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Application of Artificial Intelligence-based Digital Pathology in Biomedical Research

  • Jin Seok Kang
    • 대한의생명과학회지
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    • 제29권2호
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    • pp.53-57
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    • 2023
  • The main objective of pathologists is to achieve accurate lesion diagnoses, which has become increasingly challenging due to the growing number of pathological slides that need to be examined. However, using digital technology has made it easier to complete this task compared to older methods. Digital pathology is a specialized field that manages data from digitized specimen slides, utilizing image processing technology to automate and improve analysis. It aims to enhance the precision, reproducibility, and standardization of pathology-based researches, preclinical, and clinical trials through the sophisticated techniques it employs. The advent of whole slide imaging (WSI) technology is revolutionizing the pathology field by replacing glass slides as the primary method of pathology evaluation. Image processing technology that utilizes WSI is being implemented to automate and enhance analysis. Artificial intelligence (AI) algorithms are being developed to assist pathologic diagnosis and detection and segmentation of specific objects. Application of AI-based digital pathology in biomedical researches is classified into four areas: diagnosis and rapid peer review, quantification, prognosis prediction, and education. AI-based digital pathology can result in a higher accuracy rate for lesion diagnosis than using either a pathologist or AI alone. Combining AI with pathologists can enhance and standardize pathology-based investigations, reducing the time and cost required for pathologists to screen tissue slides for abnormalities. And AI-based digital pathology can identify and quantify structures in tissues. Lastly, it can help predict and monitor disease progression and response to therapy, contributing to personalized medicine.

Diagnosis and Surveillance of Incidental Pancreatic Cystic Lesions: 2017 Consensus Recommendations of the Korean Society of Abdominal Radiology

  • Eun Sun Lee;Jung Hoon Kim;Mi Hye Yu;Seo-Youn Choi;Hyo-Jin Kang;Hyun Jeong Park;Yang Shin Park;Jae Ho Byun;Sang Soo Shin;Chang Hee Lee;Korean Society of Abdominal Radiology
    • Korean Journal of Radiology
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    • 제20권4호
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    • pp.542-557
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    • 2019
  • The occurrence of incidentally detected pancreatic cystic lesions (PCLs) is continuously increasing. Radiologic examinations including computed tomography and magnetic resonance imaging with magnetic resonance cholangiopancreatography have been widely used as the main diagnostic and surveillance methods for patients with incidental PCLs. Although most incidentally detected PCLs are considered benign, they have the potential to become malignant. Currently, we have several guidelines for the management of incidental PCLs. However, there is still debate over proper management, in terms of accurate diagnosis, optimal follow-up interval, and imaging tools. Because imaging studies play a crucial role in the management of incidental PCLs, the 2017 consensus recommendations of the Korean Society of Abdominal Radiology for the diagnosis and surveillance of incidental PCLs approved 11 out of 16 recommendations. Although several challenges remain in terms of optimization and standardization, these consensus recommendations might serve as useful tools to provide a more standardized approach and to optimize care of patients with incidental PCLs.