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원저 : 종이의무기록과 전자의무기록의 기재 충실도 및 일치도 비교 연구: 의사의 입원,퇴원기록지와 간호사의 입원,퇴원간호정보기록지를 중심으로

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Author(s)
박희준윤경일김윤년
Alternative Author(s)
Park, Hee JunYoon, Kyung IlKim, Yoon Nyun
Issued Date
2010
Keyword
Paper-based medical recordElectronic medical recordCompletenessAccordance
Abstract
This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor`s admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor`s admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor`s admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking(p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.
Alternative Title
A Study of Comparing the Paper-Based Medical Record with the Electronic Medical Record on the Level of Medical Record Completeness and the Accordance
Department
Dept. of Biomedical Engineering (의용공학과)
Dept. of Medical Humanities (의료인문학)
Dept. of Internal Medicine (내과학)
Publisher
School of Medicine
Citation
병원경영학회지, Vol.15(1) : 1~12-1~12, 2010
Type
Article
ISSN
1226-6299
URI
http://kumel.medlib.dsmc.or.kr/handle/2015.oak/36500
Appears in Collections:
1. School of Medicine (의과대학) > Dept. of Biomedical Engineering (의용공학과)
1. School of Medicine (의과대학) > Dept. of Internal Medicine (내과학)
1. School of Medicine (의과대학) > Dept. of Medical Humanities (의료인문학)
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