의무기록의 질에 영향을 미치는 요인 분석 : 주치의사의 관심도를 중심으로 focused on physician's commitment = A Study on the Factors Related to the Quality of Medical Records

다국어 초록 (Multilingual 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.