Teaching experience for medical students to complete problem-oriented medical records in undergraduate medical practice / 医学教育

1) A possible reason that medical students do not complete problem-oriented medical records is a problem in putting information received from patient into a problem list.<br>2) We invented a clinical case and asked students to list problems from the case and to establish an initial plan for admission. The exercise was effective for teaching students to complete medical records.

Usefulness of electronic medical record system for clinical clerkship / 医学教育

We compared the effects on clinical clerkships of an electronic medical record (EMR) system and a standard medical record system. Using an EMR system, students described medical records with a problem-oriented medical record system/subject objective assessment, and plan that was much better than the standard medical record system. In the EMR system, students cannot see physicians' medical records, including laboratory data and X-ray films. Instead, students themselves must obtain the patient history and request examinations as physicians do. This system helps supervisors give suitable comments and provide data that students have requested. Directors can also evaluate supervisors by reviewing their comments. Therefore, an EMR system has the advantage of problem-oriented medical record system-based learning for students and is also useful for clinical clerkships.

Development of Psychiatric Computerized Medical Records System / 신경정신의학

OBJECTIVES: Computer-based patient record (CPR, Electronic medical record) improves the quality of medical record which reflects the quality of clinical practice. It provides more efficient and convenient way of input, retrieval, storage, communication and management of medical data. The purpose of this study was to develop a practical domestic model and theoretical basis for CPR for psychiatric patients. This model can be applied in other clinical departments. METHODS: The contents and types of items to be included in the data-base were determined through consensus meetings of investigators on the basis of our previous works on the 'comprehensive assessment of symptoms and history in psychiatric disorders' and analysis of structure and items of medical records. The computer program(Asan Medical Center Psychiatric Information System, APIS, version 1.0) was developed using Oracle 7-3-4, Power builder 4.0, Hangul Windows NT and TCP/IP as a programming, development tools, system operation and transmission protocol. RESULTS: The characteristics of APIS are as follows. 1) APIS ensures comprehensive and high quality psychiatric record through combinations of free-text and structured data format and through many available 'help pop-up windows' of required items for better documentations. 2) APIS provides convenient and efficient ways of data input, particularly for narrative input of texts, with various tools such as 'template copy', various 'pop-up lists for block or phrase copy'. 3) APIS enables users to create and modify the template files or scales for research. 4) APIS which adopted principles of POMR (Problem Oriented Medical Record) makes cumbersome management of problem titles very convenient 5) APIS also provides additional statistics necessary for hospital audit and managements as well as mail communication and schedule management of department. 6) Access to APIS requires authorized ID and password where several levels of privileges (view only, edit allowed, master) are assigned to secure the data. And also modification of data was not allowed after completion of medical record except by persons with master ID. User's password and the data before modification can be traced. CONCLUSIONS: Our study results demonstrate the practical model and theoretical basis for CPR for psychiatric patients. We believe that this model and methods contained in this program can also be applied for developments of CPR for other clinical departments.

Analysis and Evaluation of Problem Lists During Pediatric Bedside Learning / 医学教育

We analyzed and evaluated problem lists compiled by students during bedside learning. Ninety percent of the items on problem lists were medical problems, 4% were psychological problems, and 6% were social problems. Among medical problems, items related to laboratory data were most prominent, followed by data from physical examination, symptoms, and complications. Highly evaluated problem lists contained items related to psychological problems and social problems, while poorly evaluated lists did not include such items. Students with good scores on problem lists also achieved good scores in problem-oriented system fields other than compiling problem lists. It was extremely useful for students to write problem lists on problem-oriented system bedside learning.

The Mode of Medical Inference in the History of Medicine / 의사학

In the primitive ages the system of thought about health and disease was a closed system of thought which had the premise of witchcraft. In the ancient and middle ages the problems of health and disease had been dealt with within logical thinking but the phenomena of human life had been explained metaphysically and the medical problems had been inferred from deductive logic. The abnormalities of health problems which were inferred from deductive logic had not been substantiated because anatomy, physiology and technology had not been advanced far enough. In the Renaissance and modern ages the knowledge of anatomy, physiology and pathology of living body have begun to increase. The human body could be explained in the terms of structure and function of the body as a machine. Approaching this way the disease has been understood as the abnormality of structure or function of the body and the problems of health and disease are inferred from inductive logic. Recently patterns of health disorders have changed. Such health disorders that can not be found to have evidences of structural or functional abnormalities have increased. Practitioners have tended to find evidences of structural or functional abnormality of the body by using medical equipments. This way of medical practice has led to high cost of medical fees, dehumanizing health care and have produced public dissatisfaction. The form of problem-oriented medical record is recommended as the best tool for training reasonable medical inferences.

The Mode of Medical Inference in the History of Medicine / 의사학

In the primitive ages the system of thought about health and disease was a closed system of thought which had the premise of witchcraft. In the ancient and middle ages the problems of health and disease had been dealt with within logical thinking but the phenomena of human life had been explained metaphysically and the medical problems had been inferred from deductive logic. The abnormalities of health problems which were inferred from deductive logic had not been substantiated because anatomy, physiology and technology had not been advanced far enough. In the Renaissance and modern ages the knowledge of anatomy, physiology and pathology of living body have begun to increase. The human body could be explained in the terms of structure and function of the body as a machine. Approaching this way the disease has been understood as the abnormality of structure or function of the body and the problems of health and disease are inferred from inductive logic. Recently patterns of health disorders have changed. Such health disorders that can not be found to have evidences of structural or functional abnormalities have increased. Practitioners have tended to find evidences of structural or functional abnormality of the body by using medical equipments. This way of medical practice has led to high cost of medical fees, dehumanizing health care and have produced public dissatisfaction. The form of problem-oriented medical record is recommended as the best tool for training reasonable medical inferences.