The purpose of this study is to present basic data to the improvement of Medical Record Management through t-he analysis of History & Physical Examination, Progress Note, Operation Record, Physician´s Orders, Consultation Record and Nurse´s Record.
The major results were as follow;
1. The tittle of. the medical record was being used differently History & Physical Examination is 3 different tittles, 4 different tittles in Progress Note, 5 different tittles in Operation Record, 4 different tittles in Physician´s Orders, 4 different tittles in Consultation Gecord, 5 different tittles in Nurse´s Record.
2. This study :identified 6 same items(Name, Hospital No, Chief Complaints, Present Illness, Familly History, Past History) in History & Physical Examination´s items, 0 same item in Progress Note´s itemes, 6 same items(Name, Hospital No, Date, Preoperative Diagnosis, Postoperative Dianosis, Surgeon) in Operation Record´s items, 5 same it:ems(Hospital No, Date, Name, Sign, Or-der) in Physician´s Order´s items, 3 same items(Hospital No, Name, Answer) in Consultation Record´s items, and 5 same items(Name, Hospital No, Date, Note(observation)) in Nurse´s Record´s itemes.
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