RESUMEN
The purpose of this study is to identify standardized items from Hospital Discharge Abstract and Analysis data by using UHDDS(Uniform Hospital Discharge Data Sets in USA) and to ascertain the computerization in tertiary hospitals. The data were collected by questionnaire survey, responded 38 hospitals(86.4%) out of 44 tertiary hospitals, and the conclusions are as follows. 1. As for the general characteristics of patient; hospital registration number, patient name, sex and social identification number were reported to 0.92%. 2. As for admission and discharge aspects; admission date was showed 0.92, type of admission and insurance were 0.87%, discharge date 0.92%, the code of primary condition, other diagnoses and primary procedure were 0.89%, disposition of discharge was 0.61%. 3. As for the other characteristics; attending physician license number and name of operating physician were showed 0.87%, birth weight of newborn 0.74%, nationality 0.44%. 4. As for the order communicating system, computerization for the medical record management was showed 57.9%, administration of outpatient 53.6%, administration of inpatient 44.7%, administration of emergency care 28.9%. Judging from the study, the development of Korean Uniform Hospital Discharge Data Sets using Discharge Abstract and Analysis System is applicable to the national wide collection of statistics on the diseases for the discharged patients.
Asunto(s)
Humanos , Recién Nacido , Peso al Nacer , Sistemas de Computación , Conjunto de Datos , Diagnóstico , Servicios Médicos de Urgencia , Etnicidad , Estudios de Factibilidad , Pacientes Internos , Seguro , Concesión de Licencias , Registros Médicos , Pacientes Ambulatorios , Encuestas y Cuestionarios , Identificación Social , Centros de Atención Terciaria , Atención Terciaria de SaludRESUMEN
We surveyed the generation rate of health statistics by medical records offices of the 78 hospitals and its automation rate using computerized hospital information system. Structured questionnaire was given to one medical record officer of each hospital. Items in the questionnaire was selected from statistics required for hospital service evaluation or OECD health statistics. More than 50% of the medical record office generated questioned health statistics, and most of them was automated. Because many of the medical record offices of the hospitals are producing essential health statistics and automated, there is a possibility that we can collect and use these datas to build up national health database if adequate standardization procedure can be implemented.