http://chineseinput.net/에서 pinyin(병음)방식으로 중국어를 변환할 수 있습니다.
변환된 중국어를 복사하여 사용하시면 됩니다.
- 中文 을 입력하시려면 zhongwen을 입력하시고 space를누르시면됩니다.
- 北京 을 입력하시려면 beijing을 입력하시고 space를 누르시면 됩니다.
RISS 인기검색어
- 검색키워드
- 저자 : 김양담 (검색결과 2 건)
- 무료
- 기관 내 무료
- 유료
-
-
의무기록 서식의 표준화를 위한 조사 : "퇴원환자 요약자료,입퇴원기록지.퇴원요약지를 중심으로"
신종연,김양담 중앙의학사 1986 中央醫學 Vol.50 No.2
Hospital discharge abstract data, admission & discharge record, and discharge summary in the medical record are known as the most useful sourec of clinical information for hospital statistics. This study was designed to investigate the contents of discharge abstract data, admission & discharge record, and discharge summary being currently used, and to find out some basic data items that could be used in common for efficient health information. This study dealt with 39 general hospitals in Seoul. The major results were as follows; 1. The tittle of the medical record was being used differently discharge abstract data is the six different tittle, 16 different tittle in admission & discharge record, 8 different tittles in discharge summary. 2. The 30.8% (12 hospitals among 39) was being used either only admission and discharge record, or discharge summary or no forms. They are all less than 300 bed counts. 3. This study identified 83 different items and 14 same items in 6 discharge abstract data, 56 different items and 2 same items in 26 admission & discharge record, 33 different items and same a single item in discharge summary. 4. The following 20 items as a basic data in discharge abstract data: ① Hospital unit number. ② security identification number. ③ Address ④ Admission & discharge date ⑤ Attending physicians ⑥ Department & hospital days of transfer ⑦ No. of consult ⑧ discharge result ⑨ final diagnosis and code No. ⑩ operation procedures, and code no. ⑪ Type of patient ⑫ No. of biopsy ⑬ Type of anesthesia ⑭ department of consult ⑮ Death classification (16) Infertility (17) Postoperation infection (18) Cesarean section (19) Signature of medical record technician (20) Therapeutic abortion.
연관 검색어 추천
이 검색어로 많이 본 자료
활용도 높은 자료
