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KMID : 0603819960020020487
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Journal of Experimental & Biomedical Science
1996 Volume.2 No. 2 p.487 ~ p.494
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이정화
채영문/홍준현/이해종
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Abstract
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The purpose of this study was to identify important items from the medical records to be used in the standardized dischange abstract.
Thirty eight common items were identified by analyzing medical records from the 11 largest hospitals in Seoul.
Eighty two non-common items were identified from the analyzed.
Of these, 10 items were found to be important items for the dischange abstract.
Another 26 important non-common items were identified by a questionnaire survey from the directors medical record departments of 152 teaching hospitals.
Most hospitals obtain a lot of medical information from the computerized dischange abstract.
One of the results of the lady showed that the concerned sheet can be used as both the data for the medical insurance claims and the basic data for medical quality improvement.
Therefore, the dischange abstract should be regarded as the most necessary sheet to be standardized.
It was found that 92.8% of the directors of medical record departments of nationwide teaching hospitals knowledged the necessity of standardization of medical record data set.
In the future, doctors´opinion on the standardization of medical record should also be included to improve its credibility as well as usefulness.
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KEYWORD
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