| 의무기록의 질에 영향을 미치는 요인 분석 - 주치의사의 관심도를 중심으로 - |
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| 홍준현1, 최귀숙2, 이은미1 |
1세브란스병원 의무기록과
2연세대학교 보건대학원 |
| A Study on the Factors Related to the Quality of Medical Records - focused on physician's commitment - |
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| Joon Hyun Hong1, Kwisook Choi2, Eun Mee Lee1 |
1Department of Medical Record, Severance Hospital
2Graduate School of Health Sciences and Management, Yonsei University |
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| Abstract |
Background
As many previous studies proved, the quality of medical record is thought to reflect the quality of care. In this study, we analyzed the relationship between the quality of record and some factors influencing the quality of record, especially the commitment of the attending physician. Method : We developed checklist for evaluation of medical record with 36 criteria. 300 inpatient records of 10 attending physicians' patients were evaluated and the quality' of records were scored. The attending physician's commitment to medical records were scored by 34 residents. The relationship of the quality of records with physician's commitment to records, and some other factors were analyzed.
Results
More than 75% of the immediate postoperative notes on the progress note were missed. More than 69% of the contents of explanation about the procedures on the consent form or on the other forms were also missed. The physician whose quality score of records was the highest(78.9) got the highest commitment score. The score of attending physician's commitment to the record, and his seniority were positively related with the quality score of his medical records when number of patients and department were adjusted.
Conclusion
The quality of the 5 forms of the record reviewed were evaluated as moderate or excellent except 2 or 3 items. The quality of record was positively related with the attending physician's commitment to the record, and the seniority of the physician. |
| Key words
quality of medical record;quality score of record;attending physician's commitment; |
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