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Analysis of Emergency Department Medical Records of Teaching Hospitals in Korea

Other Titles
 전국 응급의학과 수련병원의 응급실 병력지에 대한 분석 
 임태호  ;  임 훈  ;  이종호  ;  강형구  ;  장문준  ;  조광현  ;  장석준  ;  김승호  ;  정상원 
 Journal of the Korean Society of Emergency Medicine (대한응급의학회지), Vol.11(4) : 464-474, 2000 
Journal Title
Journal of the Korean Society of Emergency Medicine(대한응급의학회지)
Issue Date
ED medical record ; Data element ; Redesign
Background: This study was designed to analyze the current emergency department(ED) medical
records of teaching hospitals in Korea.
Methods: The five-item questionnaires were mailed to the EDs of 40 hospitals. Among them, 27
questionnaires and 35 ED medical records were returned for reply rates of 67.5% and 87.5%, respectively.
Results: 1) The actual number of data elements in the ED medical records used by each hospital varies
widely. It ranges from 1 to 15 data elements with an average of 7.5 data elements. 2) Thirteen data
elements, signature of nurse, checklist style in review of systems, checklist style in physical examination,
neurologic examination, figure of face, Glasgow coma scale, trauma scale, treatment plan, mode of transfer,
condition on transfer, documents sent with patient, condition on discharge or discharge instruction, use of
pediatric chart and vaccination history are used by less than 50% of the medical records examined. 3) There
was no difference in the total number of data elements or in redesign and computerization of ED medical
record based on the location of the hospital, the type of hospital administration, or the number of years since
the start of EM residency program. 4) There was a statistically increased number of data elements in
redesigned medical records. 5) In the survey, 89% of the residents replied that medical records needed to be
redesigned. With respect to uniformity, 58% of the residents disagreed. A well-designed checklist chart
rather than a descriptive chart was preferred by 89% of the residents.
Conclusion: The currently used ED medical records have much room for improvement. The age of the
ED had little impact on the quality of ED medical records. More attention and effort in this field are
needed. In addition, The Korean Society of Emergency Medicine should provide guidelines for ED
medical records.
Files in This Item:
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Appears in Collections:
1. College of Medicine (의과대학) > Dept. of Emergency Medicine (응급의학교실) > 1. Journal Papers
Yonsei Authors
Kim, Seung Ho(김승호)
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