• Korea Journal of Hospital Management
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• v.15 no.1
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• pp.1-12
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• 2010

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.

• Journal of Pharmacopuncture
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• v.21 no.3
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• pp.195-202
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• 2018

Objectives: The study was to survey use of electronic medical records in subjects of Korean medicine doctors working for Korean medicine organizations and to contemplate ways to develop utilization of electronic medical records. Methods: On August 2017, it conducted online self-reported survey on subjects of Korean medicine doctors at Korean hospitals and clinics who agreed to participate in the study. A total 40 doctors in hospital and 279 doctors in clinic were included. The surveyed contents include kinds of electronic chart, reason for not using electronic medical records and problems with creation of medical records. Results: It finds that 100% of those working at Korean medicine hospitals and 86.4% of those at Korean medicine clinics have used electronic medical records. Subjects answered the biggest reason for not using electronic medical records was inconvenience. The most serious problems with creation of electronic medical records at Korean medicine organizations found in the study include there was no method of creation of medical records and no standardized terminology for use in electronic medical records. Conclusion: For utilization of electronic medical records at Korean medicine organizations, standardization of terminology, development of EMR in favour of its users and development of strategy that motivates use of EMR are required.

• Journal of Korean Society of Archives and Records Management
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• v.20 no.3
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• pp.55-76
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• 2020

Although most medical institutions in Korea use electronic medical records (EMR), there are many problems in the management and preservation of records when such medical institutions are closed. Records of closed medical institutions need to be systematically managed; however, the rate of closed medical institutions transferring records to public health centers is significantly low. Given that each medical institution has a different system and format, public health centers often cannot access records. In addition, there are no management standards that suit the reality of public health centers and the specificity of EMR. Recently, a strengthened Medical Law has been passed wherein records of closed medical institutions should be kept by health centers; therefore, this study focused on drawing up measures for efficient records management by public health centers. To this end, the relevant laws and management status were identified and an interview was conducted. After analyzing the problems, improvement plans in institutional, technical, and administrative aspects were proposed.

• Journal of the Korean Data and Information Science Society
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• v.14 no.4
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• pp.817-824
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• 2003

We employed a hierarchical document classification method to classify a massive collection of electronic medical records(EMR) written in both Korean and English. Our experimental system has been learned from 5,000 records of EMR text data and predicted a newly given set of EMR text data over 68% correctly. We expect the accuracy rate can be improved greatly provided a dictionary of medical terms or a suitable medical thesaurus. The classification system might play a key role in some clinical decision support systems and various interpretation systems for clinical data.

• Journal of the Semiconductor & Display Technology
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• v.13 no.2
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• pp.63-66
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• 2014

Managing electronic medical record is very difficult, because the currently electronic medical system is not designed standard that is uniform and proper. In this paper, in order to overcome this situation, we propose meta-data for the management of the electronic medical record as a single system. To this end, we first analyzed the research on electronic medical records and related standards. Second, we, on the basis of the analysis result, abstracted electronic medical record and entities related on electronic medical, and we designed an entity-relationship model. And finally, we have to complete the meta-data through the setting attributes in this entity-relationship model. Through this study, it was possible that we can complete metadata highly expressive medical records, and suggest an alternative for problem of current medical records systems.

• The Korean Society of Law and Medicine
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• v.11 no.2
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• pp.309-335
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• 2010

This study is a paper reviewed legal status of medical personnel and issues of law on recently discovered medical records. As the increase of medical personnel who have gone through the administrative disposal in regards to the medical records, it is needed to examine the legal issue or dispute on the medical records under the current law. Medical records are the statement on patient's medical conditions made by the medical personnel. This records are used as important source for patient's further treatment. This becomes the communication route between the patients and the other medical personnel, and it provides the patients a right to find out their medical information. According to the Medical Service Act (Article 21), a medical personnel shall prepare respectively a record book of medical examination and treatment. And medical personnel shall make a signature. Furthermore, the medical personnel or the opener of the medical institutions must preserve the record book (including an electronic medical record). Meanwhile, the issues of a ban on false entry, additional record, revision or manipulation on the medical record have been recently on the rise. This paper briefly examined the major issues in regards to the medical records. It especially clarified the legal duty on medical records and its major-contentious-issues. At the same time, it pointed out the problems of the unreasonable over interpretation of the law. Furthermore, this suggested the guidelines for the further discussion and review.

• Journal of Society of Preventive Korean Medicine
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• v.18 no.3
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• pp.11-21
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• 2014

The rapid development and distribution of information communication industry facilitates the changes of hospital administration, introducing EMR(Electronic Medical Record) instead of paper-based medical record in the medical field. The developed countries such as U.S. have established EMR system after in the middle of 1970s because the primary advantages of EMR is to store and handle vast amounts of records efficiently and increase the quality of health care. Most of health organizations in Korea also apply medical record system to their administration. As the result, they have accomplished a scientific administration system through the use of medical record to handle a variety of patient's information including patient's confidentiality and privacy such as family history, social status, income level, and so on. However, access to and the misuse of EMR causes illegal infringement of patient's information and finally it becomes a very serious medical issue. Potential leakage and misuse of records may seriously infringe patient's privacy rights. In this respect, the related agencies in the public and private sector have been making efforts to prevent patient's records leakages. Especially, the revision bill of Medical Law in 2002 establishes the ways on the security and standards of electronic records. However, it does not provide the proper guidelines which is applied to the rapid changes of the medical environment. One of the most priorities in the hospital administration is the production and maintenance of an accurate medical records fulfilled by medical recorders. Therefore, it is very important for health care providers to hire ethical-based medical recorders. But, unfortunately most of hospitals overlook the importance of their roles. All parts including government, physician and patient must have more concerns on the problems related to EMR. Therefore, this study aims to propose the proper ways to resolve the problems coming from EMR.

• Journal of Korean Society of Archives and Records Management
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• v.13 no.1
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• pp.107-134
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• 2013

Many hospitals introduce the electronic medical record systems (EMRS) to implement a digital type of hospital. However, there are various problems in managing and preserving medical records. Systems, such as OCS, PACS, and EMR, are independently operated without formal standards related to medical records management. To manage medical records effectively, distributed medical records including paperand electronic-type should be managed in an integrated manner. With its analysis of the current status in the management of medical records of J University Hospital, this study proposes methods to solve the problems extracted from the results of the analysis, and a management model for an integrated medical records management based on the process of records management of ISO 15489.

• Journal of information and communication convergence engineering
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• v.18 no.4
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• pp.260-266
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• 2020

This study presents the categorical structure for ther epresentation of a 3D human body position system in the WD stage after NP approval by the International Organization for Standardization (ISO), analyzes the needs of electronic medical record users and establishes future implementation plans for expanding its use in Korea. Research was conducted on the needs of doctors, nurses, health and medical information managers, and radiology departments, which are the main stakeholders of electronic medical records. The overall requirements for electronic medical records were derived from the results, and the requirements for each stage of use of electronic medical records were analyzed. Based on the results of the study, the study proposes plans to expand the use of the categorical structure for the representation of the 3D human body position system, and also aims to establish a standard system for health and medical terminology in Korea and contribute to the development of health and medical information standards through international standardization.

• Journal of Digital Contents Society
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• v.11 no.2
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• pp.135-144
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• 2010

Medical records are very important records and should not be modified after creation. The current medical records are liable to improper modification. With the development of information technology, electronic medical records (EMR) are used widely. For the EMR, cryptographic primitives may be used to develop techniques to prevent medical record modofication. In this research, a technique to prevent improper medical record prevention is proposed. It uses crytographic primitives such as linked hash, digital signature, and electronic notarization. A prototype system is also developed for performance analysis. The proposed method makes the medical record modification impossible with a small amount of additional cost.