지원사업
학술연구/단체지원/교육 등 연구자 활동을 지속하도록 DBpia가 지원하고 있어요.
커뮤니티
연구자들이 자신의 연구와 전문성을 널리 알리고, 새로운 협력의 기회를 만들 수 있는 네트워킹 공간이에요.
논문 기본 정보
- 자료유형
- 학술저널
- 저자정보
- 발행연도
- 2012.1
- 수록면
- 10 - 17 (8page)
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초록· 키워드
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Objectives: Clinical documents (CDs) have evolved from traditional paper documents containing narrative text information into the electronic record sheets composed of itemized records, where each record is expressed as an item with a specific value. We defined medical record (MR) items to be information entities with a specific value. These entities were then used to compile form-based clinical documents as part of an electronic health record system (EHR-s). Methods: We took a reusable bottom-up developmental approach for the MR items, which provided three things: efficient incorporation of the local needs and requirements of the medical professionals from various departments in the hospital, comprehensive inclusion of the essential concepts of the basic elements required in clinical documents, and the provision of a structured means for meaningful data entry and retrieval. This paper delineates our experiences in developing and managing medical records at a large tertiary university hospital in Korea. Results: We collected 63,232 MR items from paper records scanned into 962 CDs. The MR item database was constructed using 13,287 MR items after removing redundant items. During the first year of service users requested changes to be made to 235 (1.8%) attributes of the MR items and also requested the additional 9,572 new MR items. In the second year, the attributes of 70 (0.5%) of the existing MR items were changed and 3,704 new items were added. The number of registered MR items increased by 72.0% in the first year and 27.9% in the second year. Conclusions: The MR item concept provides an easier and more structured means of data entry within an EHR-s. By using these MR items, various kinds of clinical documents can be easily constructed and allows for medical information to be reused and retrieved as data.
The success of the use of MR items in a large tertiary university hospital system provides evidence that verifies our approach as being an efficient means of user-oriented and structured data entry, enabling the easy reuse of medical records.
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참고문헌 (12)
참고문헌 신청
Dolin RH. / 2001 / The HL7 clinical document architecture / J Am Med Inform Assoc 8 : 552 ~ 569
Eduljee A. / 2003 / Practical evaluation of clinical guideline document models / AMIA Annu Symp Proc : 836 ~
Elevitch FR. / 2005 / SNOMED CT : electronic health record enhances anesthesia patient safety / AANA J 73 : 361 ~ 366
Elkin PL. / 2002 / Guideline and quality indicators for development., purchase and use of controlled health vocabularies / Int J Med Inform 68 : 175 ~ 186
Elkin PL. / 2003 / A formal representation for messages containing compositional expressions / Int J Med Inform 71 : 89 ~ 102
Eduljee A. / 2003 / Practical evaluation of clinical guideline document models / AMIA Annu Symp Proc : 836 ~
Elevitch FR. / 2005 / SNOMED CT : electronic health record enhances anesthesia patient safety / AANA J 73 : 361 ~ 366
Elkin PL. / 2002 / Guideline and quality indicators for development., purchase and use of controlled health vocabularies / Int J Med Inform 68 : 175 ~ 186
Elkin PL. / 2003 / A formal representation for messages containing compositional expressions / Int J Med Inform 71 : 89 ~ 102
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