종이의무기록과 전자의무기록의 기재정도 및 일치도 비교 연구:  심방세동 환자 입원기록을 중심으로

신아미; 박희준; 정선주; 노미진; 김윤년

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자료유형: 학술저널

저자정보: 신아미 박희준 정선주 노미진 김윤년

저널정보: 대한의료정보학회 Healthcare Informatics Research Healthcare Informatics Research 제15권 제2호

발행연도: 2009.1

수록면: 201 - 208 (8page)

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연구주제

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연구배경

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연구방법

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연구결과

초록· 키워드

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Objective: This aim of this study was to evaluate the quality and agreement of electronic medical records with paper-based medical records. Methods: Data was collected from the paper-based medical records generated during 2004 and electronic medical records during 2007, in patients hospitalized for arterial fibrillation. The categories evaluated included the chief complaint, history of present illness, past illness, medication history, admission history, family history, allergies, smoking history, and drinking history in admission record. Results: The electronic medical records scored higher for: the existence of a medical record, level of information in the medical record and agreement of information. However, there were some categories of disagreement between the information from doctors and nurses, and there were several categories with no record by doctors or nurses. Conclusion: The results of this study confirmed that the quality of the electronic medical record is better than that of paper-based medical with regard to: the existence of the record, level and agreement of information. However, there are discrepancies in the information contained within both types of records.

#Medical Record #Hospital Information System #Evaluation

참고문헌 (13)

참고문헌 신청

Choi HJ / 2003 / Core data set from medical record forinformation sharing between health care institutions / 박사 / Yonsei University

Chung YJ / 2005 / A study of the completeness of medicalrecord of system of the EMR / 박사 / Daejeon University

Hammond KW / 2003 / Brathwaite-Sketoe Bm. Are electronic medical record trustworth?Observations on copying, pasting and duplication / AHIMA Annu Symp Proc : 269 ~ 273

Hong JH / 1996 / A study on the factorsrelated to the quality of medical records-focused onphysician's commitment / J Korean Soc Qual Assur Health Care 5 (1) : 16 ~ 26

Jung MJ / 2005 / Comparison of documentation completenessbetween the paper-based medical record and theelectronic medical record / 박사 / Yonsei University

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