13 research outputs found
(A) study on the level of medical record documentation and agreement in the information on the patient's past history
๋ณ์ํ์ ํ๊ณผ/์์ฌ[ํ๊ธ]
์ด ์ฐ๊ตฌ๋ ํ์ ๊ณผ๊ฑฐ๋ ฅ ์ ๋ณด์ ๊ฐ ํญ๋ชฉ๋ณ๋ก ์์ฑ๋์ด์ผ ํ ๊ธฐ์ฌ์์ค์ ์ค์ ํ์ฌ ์ด ๊ธฐ์ค์ ๊ทผ๊ฑฐํ์ฌ ์ค์ ์๋ฌด๊ธฐ๋ก์ ๊ฒํ ํจ์ผ๋ก์จ ๊ทธ ์์ ์ฑ์ ๋ถ์ํ๊ณ , ์๋ก ๋ค๋ฅธ ๊ธฐ๋ก์ ์ง๋จ์ด ๋์ผํ ์ ๋ณด๋ฅผ ๊ฐ์ ๊ธฐ๋กํ๋ ์์ ๊ฐ ๋ด์ฉ์ ์ผ์น๋๋ฅผ ํตํด ๊ทธ ์ ๋ขฐ์ฑ์ ๋ถ์ํ๊ณ ์ ํ์๋ค. 2004๋
์ฐ๊ตฌ๋์๋ณ์์ ์์์ผ๋ก ์ต์ด ์
์ํ 403๋ช
์ ์ธํด ๊ธฐ๋ก, ์ ๊ณต์ ๊ธฐ๋ก, ๊ฐํธ์ฌ ๊ธฐ๋ก์ ๊ณผ๊ฑฐ๋ ฅ ์ ๋ณด๋ฅผ ๋์์ผ๋ก ํ์ฌ ๊ธฐ์ฌ์ฌ๋ถ, ๊ธฐ์ฌ์ ๋, ์ฐ๊ตฌ๋์๋ณ์์ ๊ธฐ์ฌ ๊ธฐ๋์์ค ์ถฉ์กฑ์ ๋, ๋ด์ฉ ์ผ์น๋๋ฅผ ๋ถ์ํ์๋ค.๋ถ์ ๊ฒฐ๊ณผ๋ ๋ค์๊ณผ ๊ฐ๋ค.์ฒซ์งธ, ๊ฐ ํญ๋ชฉ์ ๊ธฐ์ฌ์จ์ ์ฃผ์ ๋ฐ ํ์ง๋ณ์ํ, ๊ณผ๊ฑฐ๋ณ๋ ฅ์ ๋์๊ณ , ์
์๋ ฅ, ์๋ ๋ฅด๊ธฐ, ํฌ์ฝ๋ ฅ์ ๋ฎ์๋ค. ์๋ ๋ฅด๊ธฐ์ ๊ฒฝ์ฐ ์ ๊ณต์ ๊ธฐ๋ก์๋ ๊ฑฐ์ ๊ธฐ์ฌ๋๊ณ ์์ง ์์๊ณ , ํฌ์ฝ๋ ฅ์ ์ธ ์์ ๋ชจ๋์์ ์์ฑ๋์ง ์์ ๊ทธ ๋ด์ฉ์ ์ ์ ์๋ ๊ฒฝ์ฐ๊ฐ 10%์ ๋ฌํ์๋ค. ๊ธฐ๋ก์ ์ง๋จ๊ณผ ์
์๊ณผ์ ๋ฐ๋ผ ํญ๋ชฉ๋ณ๋ก ๊ธฐ์ฌ์จ์ ํฐ ์ฐจ์ด๊ฐ ์์๋ค.๋์งธ, ๊ณผ๊ฑฐ๋ ฅ ํญ๋ชฉ์ ๊ธฐ์ฌ์ ๋๋ฅผ ๊ฐ ํญ๋ชฉ๋ณ๋ก โ๊ธฐ์ฌ์ ๋ 1โ์์ โ๊ธฐ์ฌ์ ๋ 4โ๊น์ง ๊ตฌ๋ถํ์ฌ 1์ ์์ 4์ ์ผ๋ก ์ ์ํ ํ์๋ค. ๊ทธ ์์ค์ ์ธก์ ํ ๊ฒฐ๊ณผ ์
์๋ ฅ, ๊ณผ๊ฑฐ๋ณ๋ ฅ, ๊ฐ์กฑ๋ ฅ์ด โ3 ์ ๋โ์๊ณ ํก์ฐ๋ ฅ, ํฌ์ฝ๋ ฅ, ์ฃผ์ ๋ฐ ํ์ง๋ณ์ํ, ์์ฃผ๋ ฅ, ์๋ ๋ฅด๊ธฐ๋ โ2 ์ ๋โ๋ฅผ ๋ณด์๋ค. ์์ฑ์ ์ง๋จ์ ๋ฐ๋ผ ํญ๋ชฉ๋ณ ๊ธฐ์ฌ์ ๋์ ์์ค์ ์ฐจ์ด๊ฐ ์์์ผ๋ฉฐ ์
์๊ณผ๋ณ๋ก๋ ๋ด๊ณผ๊ณ๋ ์ธํด ๊ธฐ๋ก์ด, ์ธ๊ณผ๊ณ๋ ์ ๊ณต์ ๊ธฐ๋ก์ด ์ฐ์ํ์๋ค. ์ฐ๊ตฌ๋์๋ณ์์ ๊ธฐ๋ก์ ์ง๋จ๊ณผ ์
์๊ณผ์ ๋ฐ๋ฅธ ์
๋ฌด์ ์ฐจ์ ์ฐจ์ด๊ฐ ๊ธฐ์ฌ์ ๋์ ๋ฐ์๋ ๊ฒฐ๊ณผ๋ฅผ ๋ณด์๋ค. ์
์งธ, ๊ธฐ์ฌํํ์ ๋ฐ๋ฅธ ๊ธฐ์ฌ์จ๊ณผ ๊ธฐ์ฌ์ ๋์ ์์ด์๋ ๊ธฐ์ฌ์จ์ ์ฒดํฌ-์์ ํผํฉํํ๊ฐ ๋์์ผ๋, ๋ด์ฉ์ ๊ธฐ์ฌ์ ๋๋ ์์ ์์ ํํ๊ฐ ์ฐ์ํ์๋ค.๋ท์งธ, ์ฐ๊ตฌ๋์๋ณ์์ ์๋ฌด๊ธฐ๋ก ์์์ด ์ ํ ๊ณผ๊ฑฐ๋ ฅ ์ ๋ณด์ ํญ๋ชฉ๋ณ ๊ธฐ์ฌ ๊ธฐ๋์์ค๊ณผ ์ค์ ๊ธฐ๋ก์ ๊ธฐ์ฌ์ ๋๋ฅผ ๋น๊ตํ์ฌ ๊ทธ ์ถฉ์กฑ์ ๋๋ฅผ ๋ณธ ๊ฒฐ๊ณผ ๊ฐ์กฑ๋ ฅ์ด ์ ์ผ ๋๊ณ ๋ค์์ ์
์๋ ฅ, ํก์ฐ๋ ฅ, ๊ณผ๊ฑฐ๋ณ๋ ฅ, ์์ฃผ๋ ฅ, ํฌ์ฝ๋ ฅ, ์๋ ๋ฅด๊ธฐ, ์ฃผ์ ๋ฐ ํ์ง๋ณ์ํ ์์ด์๋ค. ๊ธฐ์ฌ ๊ธฐ๋์์ค์ด โ๊ธฐ์ฌ์ ๋ 4โ๋ก ์์ธํ๊ฒ ๊ธฐ์ฌ๋ ๊ฒ์ ์๊ตฌํ๋ ํญ๋ชฉ์ธ ๊ณผ๊ฑฐ๋ณ๋ ฅ, ์๋ ๋ฅด๊ธฐ, ์ฃผ์ ๋ฐ ํ์ง๋ณ์ํ์ ๊ธฐ๋์์ค ์ถฉ์กฑ์จ์ ๋ค๋ฅธ ํญ๋ชฉ๋ณด๋ค๋ ์ ์กฐํ์๋ค.๋ค์ฏ์งธ, ํ์ ์
์ ์ ์ธ ๊ธฐ๋ก์ ์ง๋จ์ด ๋ฉด๋ด์ ํตํด ๊ฐ์ ๊ธฐ๋กํ๋ ์ธํด ๊ธฐ๋ก, ์ ๊ณต์ ๊ธฐ๋ก ๋ฐ ๊ฐํธ์ฌ ๊ธฐ๋ก์ ๊ณผ๊ฑฐ๋ ฅ ์ ๋ณด๋ฅผ โ๊ธฐ์ฌ์ ๋ 1โ์ ํด๋น์ฌํญ โ์์โ ๋๋ โ์์โ ์์ค์์ Kappa ๊ณ์๋ก ์ผ์น๋๋ฅผ ๋ถ์ํ์๋ค. ์ ๊ณต์ ๊ธฐ๋ก-๊ฐํธ์ฌ ๊ธฐ๋ก์ ์ผ์น๋์ ์ธํด ๊ธฐ๋ก-์ ๊ณต์ ๊ธฐ๋ก์ ์ผ์น๋๋ โ์์ฃผ ์ข์โ์์ โ๋ณดํตโ์ ์์ค์ด์๊ณ , ๊ฐํธ์ฌ๊ธฐ๋ก-์ธํด ๊ธฐ๋ก์ ์ผ์น๋๋ โ์ฝ๊ฐ ์ข์โ์์ โ๋์จโ๊น์ง์ ์์ค์ด์๋ค.๊ณผ๊ฑฐ๋ ฅ ์ ๋ณด์ ์์ ์ฑ๊ณผ ์ ๋ขฐ์ฑ ์์ค์ ๊ธฐ๋ก์ ์ง๋จ๊ณผ ์
์๊ณผ๋ณ๋ก ์ฐจ์ด๋ฅผ ๋ณด์๋ค. ๊ธฐ๋ก์ ์ง๋จ๊ณผ ์
์๊ณผ์ ๋ฐ๋ผ ํํด์ง๋ ์ง๋ฃ๊ณผ์ ์ ์ ์ฐจ๊ฐ ์๋ฌด๊ธฐ๋ก์ ์ง์ ๋ฐ์๋๋ ๊ฒฐ๊ณผ๋ฅผ ๋ณด์ฌ, ์๋ฌด๊ธฐ๋ก ์์ฑ์ ๊ณผ์ ๊ณผ ๊ธฐ๋ก์ ์ง์ ๊ดํ ์์ธํ ์ฐ๊ตฌ๊ฐ ํ์ํ์๋ค. ์์ ์ผ๋ก ๋์ ๊ธฐ์ฌ์จ์ ๋ํ๋ด๋ ํญ๋ชฉ์ด ๊ธฐ์ฌ์ ๋๋ ๋ฎ์ ์๋ฌด๊ธฐ๋ก์ ๊ธฐ์ฌ๋ ๋ด์ฉ์ ์ง์ ์ผ๋ก ์ ๊ฒํ๊ณ ํ๊ฐํ ์ ์๋ ๋๊ตฌ์ ๊ฐ๋ฐ์ด ์๊ตฌ๋์๋ค. ๋ํ ๊ธฐ์ฌ์ ๋๊ฐ ์์ธํ์ฌ์ผ ํ๋ ํญ๋ชฉ์ ๊ธฐ์ฌ์์ค์ ์คํ๋ ค ๋ฎ์ ๊ฒฐ๊ณผ๋ฅผ ๋ณด์ฌ ์์๊ณผ๋ณ ํน์ฑ์ ๋ง์ถ ๊ตฌ์ฒด์ ์ธ ์๋ฌด๊ธฐ๋ก ์์ฑ์ ๋ํ ์ง์นจ๊ณผ ๊ต์ก์ด ํ์ํ์๋ค.
[์๋ฌธ]This study was conducted to evaluate the quality in medical records by analyzing its completeness through setting up the level of record on the patient''s past history and through examining the actually medial records based on this standard, and by analyzing its reliability through the level of agreement in the contents between records that mutually different recorder groups do record the same information, respectively. Targeting the information on the patient''s past history in interns'' records, residents'' records and nurses'' records toward 403 inpatients who were admitted first in 2004 at university hospital due to stomach cancer, it analyzed the whether or not recording, the recording level, the satisfaction with the expectant level of the records in the hospital targeted for a research and the level of agreement .The results are as follows.First, as for the rate of recording each item, it was high in the chief complaint & present illness and the past illness history, and low in the admission history, allergy, and the medication history. Depending on a group of recorders and on the admission department, the recording rate showed big difference by item. This results showed that important items were different by a group of recorders and by the admission departmentSecond, as a result of measuring the level after dividing the recording level of items for the patient''s past history from Level 1 to Level 4 by each item, the admission history, the past illness history, and the family history were about Level 3, and the smoking history, the medication history, the chief complaint & present illness, the drinking history and allergy were about Level 2. By admission department, it was excellent in the interns'' records for the medical department, and in the residents'' records for the surgical department.Third, as a result of analyzing the recording rate and the recording level in contents depending on a recording form, the recording rate was high in the mixed form of check and description, but the recording level in contents was excellent in the completely descriptive form.Fourth, as a result of its satisfactory level by comparing the expectant level of a record and the actual record by item in information on the patient''s past history, which was expected by the medical-record committee members of the hospital targeted for a study, it was low in the satisfactory rate of the expectant level in the patient''s past history , in allergy, and in the chief complaint & the present illness, which are items of requiring to be recorded in detail as Level 4 in the expectant level of a record.Fifth, it analyzed the level of agreement with Kappa score in the level of โYesโ or โNoneโ related to the corresponding matter in Level 1, in terms of information on the past history in the intern''s record, the resident''s record, and the nurse''s record. The level of agreement in the resident''s record & the nurse''s record, and in the intern''s record & the resident''s record was from "excellent" to "a little good", and the level of agreement in the nurse''s record & the intern''s record was from "a little good" to "poor".There was difference in the level of completeness and in reliability for the information on the past history by recorder group or by admission department. The encounter process that was performed by the admission department or the recorder group, indicated the result that was directly reflected on the quality of medical records, thus it was required further study about the medical record documentation process and quality. The items that showed the high recording rate quantitatively were rather low, thus it was required the development of tool for the qualitative inspection and evaluation in the medical record. And the items which were needed to be detailed the record level were rather low, thus there needed a documentation guideline and education by clinical department.ope
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Thesis(master`s)--์์ธๅคงๅญธๆ ก ๅคงๅญธ้ข :ๅๅญธ้จ ้ปๆฐฃๅๅญธๅฐๆป,2006.Maste