A Survey Study of Organizational Situation of Medical Record Department for Producation of Disease Statistics on National Basis / 대한의료정보학회지

The purpose of this study was to survey the organizational situation of medical record department(MRD) in hospitals to identify the factors influencing the production ol disease statistics in Korea. 134 hospitals answered for the structured questionnaires mailed to the 218 hospitals. This studs results are as follows. 1 ) There were three types in organizational situation of MRD: independent department (70.1%) a unit in other department (26.1 %) .and in the rest 3.7%. there were no MRD or unit. 2) The differences of work performed in MR ~) or on it in the second referral level hospitals and the third referral level hospitals were statistically significant in incomplete medical record management(p<0.05) DRG coding supplying research data, quality improvement activity. cancer registration(p<0.01) and transeription of medical record( p<0.0l). 3) 66.4% of the target hospitals were performing the recheeking of disease classification data after reponsible physicians completed the incomplete record 4) statistically significant variables which affect works performed in MRD are organizational situation of MRD(<0.001) and the number of medical record professionals. 41.3% of variation of works performed in MRD was explained by variation of organizational situation and the number of medical record professionals.

Standardization Study for Discharge Abstract Data / 대한의료정보학회지

The purpose of this study was to identify important items from the medical records to be used in the standardized discharge abstract. Common items were identified by analyzing medical records from the 11 largest hospitals in Seoul. Non-common items were identified by a questionnaire survey from the directors of medical record departments of 152 teaching hospitals. The results of research was follows; 1. Thirty eight common items were included in the analyzed sheet of 11 hospitals. 2. Eighty two non-common items were identified from the analyzed. Of these,10 items were found to be important items for the discharge abstract. 3. Another 26(half) or 18(first quarter) important non-common items were identified from the survey. 4. It was notified in the non-common standardized items group that the importance of some items like the patient's occupation, underlying cause of death, nosocomial infection, complications, house staff code in charge of completing records, and items concerning quality improvement showed difference by the number of beds. The importance of house staff code who is responsible for completion of the record also showed statistically significant difference by the number of beds per medical record professional and by regions. The item of the types of nosocomial infection also showed statistically significant difference between the regions. Most hospitals obtain a lot of medical information from the computerized discharge abstract. One of the results of the study showed that the concerned sheet can housed as both the data for the medical insurance claims and the basic data for medical quality improvement. Therefore, the discharge abstract should be regarded as the most necessary sheet to be standardized. It was found that 92.8% of the directors of medical record departments of nationwide teaching hospitals acknowledged the necessity of standardization of medical record data set.

Standardization Study for Discharge Abstract Data / 대한의료정보학회지

The purpose of this study was to identify important items from the medical records to be used in the standardized discharge abstract. Common items were identified by analyzing medical records from the 11 largest hospitals in Seoul. Non-common items were identified by a questionnaire survey from the directors of medical record departments of 152 teaching hospitals. The results of research was follows; 1. Thirty eight common items were included in the analyzed sheet of 11 hospitals. 2. Eighty two non-common items were identified from the analyzed. Of these,10 items were found to be important items for the discharge abstract. 3. Another 26(half) or 18(first quarter) important non-common items were identified from the survey. 4. It was notified in the non-common standardized items group that the importance of some items like the patient's occupation, underlying cause of death, nosocomial infection, complications, house staff code in charge of completing records, and items concerning quality improvement showed difference by the number of beds. The importance of house staff code who is responsible for completion of the record also showed statistically significant difference by the number of beds per medical record professional and by regions. The item of the types of nosocomial infection also showed statistically significant difference between the regions. Most hospitals obtain a lot of medical information from the computerized discharge abstract. One of the results of the study showed that the concerned sheet can housed as both the data for the medical insurance claims and the basic data for medical quality improvement. Therefore, the discharge abstract should be regarded as the most necessary sheet to be standardized. It was found that 92.8% of the directors of medical record departments of nationwide teaching hospitals acknowledged the necessity of standardization of medical record data set.

Standardization of Code of Hospital Information / 대한의료정보학회지

The rapid change of hospital environment emphasizes the importance of hospital information system. To be effective, the definitions and codes of data which will be required by the health professionals workstation should be standardized. In Korea, many hospitals are implementing order communication system in order to expedite the patient management process, to enhance the service, and for effective management of medical information. Various codes those are in use in hospitals should be standardized for effective interdepartmental and interhospital communication. This paper shows the current status of implementing order communication system in hospitals which have more than 400 beds in Korea, application status of operation an procedure classification systems, e.g., International Classification of Procedures in Medicine, and International Classification of Diseases-9th-Clinical Modification. 22 hospitals (29.0%) are implementing inpatient OCS and 29 hospitals(38.2%) for outpatient OCS. 46 hospitals(60.5%0 are applying ICPM and among them 23 hospitals(50.0%) showed dissatisfaction for that classification system. 30 hospitals(39.5%) are applying ICD-9-CM and none of them revealed dissatisfaction for that classification system. 64 hospitals(84.2%) want new classification system for operation and procedures and 58 hospitals(76.3%) revealed the necessarily of standardization of code of physicans, clinical departments and administrative departments.

A Study on coding application of ICD-9 / 대한의료정보학회지

In Korea medical record administrators/technicians are coding diagnoses and procedures of discharged patients based on their medical records mostly using International Classification of Diseases, 9th revision(ICD-9) and International Classification of Procedures(ICPM) by WHO. This study examined consistency of coding in 63 hospitals in the year of 1992. The statistical data showed great inconsistency in coding patterns among many hospitals. The main reasons of inconsistency were coders errors, ill-defined diagnoses/procedures, no unified route to make new code numbers for the new or ambiguous diagnoses/procedures, inconsistency of selection of using optional(additional) codes, and inconsistency of reference records on coding. Near half of the hospitals do not recheck the accuracy of coding after completion of medical records by physicians. Most of the coders review operation record, admission and discharge record, discharge summary, progress notes, pathology report, and consultation record as references on coding, but 14 hospitals do not review the whole record when they code diagnoses and procedures. Twenty-three hospitals discuss with physicians when they have questions in assigning code numbers. Further study should be done continuously for valid and reliable statistics of diseases and operations and for establishing a systematic unified channel for the new and ambiguous cases.