A Study on Medical Laws and External Evaluation Criteria with Reference to the Essential Forms consisting Medical Records and to the Items for Each Medical Record

Seo, Sun Won; Kim, Kwang Hwan; Hwang, Yong-Hwa; Kang, Sunny; Kang, Jin Kyung; Cho, Woo Hyun; Hong, Joon Hyun; Pu, Yoo Kyung; Rhee, Hyun Sill

Journal of Korean Society Quality Assurance Health Care 2002;9(2): 176.
Published online December 30, 2002.

의료기관 종별 의무기록 중요서식 항목별 작성 실태 및 의무기록 완결점검표 분석

서순원¹, 김광환¹, 황용화¹, 강선희², 강진경³, 조우현⁴, 홍준현⁵, 부유경⁶, 이현실⁷

¹단국대학교병원 의무기록과
²공주대학교 보건행정학과
³연세대학교 의과대학 내과
⁴연세대학교 의과대학 예방의학교실
⁵연세대학교 보건행정학과
⁶인하대학교병원 의료정보과
⁷고려대학교병설 보건대학 보건행정학과

A Study on Medical Laws and External Evaluation Criteria with Reference to the Essential Forms consisting Medical Records and to the Items for Each Medical Record

Sun Won Seo¹, Kwang Hwan Kim¹, Yong-Hwa Hwang¹, Sunny Kang², Jin Kyung Kang³, Woo Hyun Cho⁴, Joon Hyun Hong⁵, Yoo Kyung Pu⁶, Hyun Sill Rhee⁷

¹Dept. of Medical Record, Dankook University Hospital
²Dept. of Health Administraion, Kongju National University
³Dept. of Internal Medicain, Yonsei University Hospital
⁴Dept. of Preventive Medicine, Yonsei University Hospital
⁵Dept. of Health Administration, Yonsei University
⁶Dept. of Medical Information & Record services, Inha University Hospital
⁷Dept. of Health Administration, College of Health Science, Korea University

Abstract

Backgound : This study is to suggest the standardized format of the clinical sheets and the standardized items of every clinical sheet. The standardization of the medical records will increase the faithfullnes of the contents in them and it will contribute to construct the good health information system. Method : From Jan. 1st. 2001 to March 31st 2001, we gathered as many paper clinical sheets as possible by every class of institutions to review the faithfulness of the clinical contents in them. Clinical sheets of 9 tertiary care hospitals, 6 general hospitals and 56 clinics were gathered. Two experienced medical record administrators reviewed them. The review focus was to check whether the items recommend by the hospital standardization review criteria and hospital service evaluation organization were appeared in the clinical sheets and whether the contents of every item were written.
Results
Tertiary care hospitals; In case of administrative data, the contents were filled well if the items were fixed. The clinical data like C.C, history,physical examiniation were filled well, but if the items were not fixed, some items were omitted. The result is that more items are to be filled if they are fixed. General hospitals Administrative data were filled more than 50%. Final diagnosis was filled about 66.7%.But other clinical data were not filled well and not many clinical related items were appeared in the sheets.In the legal point of view, the reason for visiting hosptals or the right diagnosis, patient condition at discharge could not be confirmed well.In surgery cases, surgical procedures could not be confirmed well as many surgical related information(surgery time, fluids and blood, number of sponges, biopsy, etc) were omitted. Clinics More than 70% administrative data were filled and fixed as items. Among the clinical related data, laboratory result was the most credible data. But without the right diagnosis, drug orders were given and doctors' written signatures were not appeared over 96.4%. So the clinical sheets cannot be used as a legal document. Conculusion : There was a tendency that the contents were filled well if the items were fixed in the documents, We also suggest a clinical check list to review the completeness and faithfulness of the clinical sheets. If many hospitals use the suggested clincal check list and if they make the necessary items fixed in the clinical sheets, the quality of the medical record will increase dramatically.

Key words Clinical sheets;Clinical sheets standardization;Medical record item standatdization;