Evaluation of Unpreparedness When Issuing Copies of Medical Records in Tertiary Referral Hospitals.
10.4258/hir.2010.16.2.120
- Author:
Myong Mo MOON
1
;
Myung Geun KANG
;
Sun Won SEO
;
Woo Sung PARK
;
Yoon KIM
;
Sung Soo KIM
;
Eun Mi CHOI
;
Jong PARK
;
Il Soon PARK
Author Information
1. Department of Medical Record and Informatics, Chosun University Hospital, Gwangju, Korea.
- Publication Type:Original Article
- Keywords:
Medical Information;
Unpreparedness Required Documents;
Medical Records;
Referral Hospitals
- MeSH:
Coat Protein Complex I;
Compliance;
Electronics;
Electrons;
Humans;
Insurance Carriers;
Logistic Models;
Medical Records;
Outpatients;
Tertiary Care Centers
- From:Healthcare Informatics Research
2010;16(2):120-132
- CountryRepublic of Korea
- Language:English
-
Abstract:
OBJECTIVES: As a baseline study to aid in the development of proper policy, we investigated the current condition of unpreparedness of documents required when issuing copies of medical records and related factors. METHODS: The study was comprised of 7,203 cases in which copies of medical records were issued from July 1st, 2007 through June 30th, 2008 to 5 tertiary referral hospitals. Data from these hospitals was collected using their established electronic databases and included study variables such as unpreparedness of the required documents as a dependent variable and putative covariates. RESULTS: The rate of unpreparedness of required documents was 14.9%. Multiple logistic regression analysis revealed the following factors as being related to the high rate of unpreparedness: patient age (older patients had a higher rate), issuance channels (on admission > via out-patient clinic), type of applicant (others such as family members > for oneself > insurers), type of original medical record (utilization records on admission > other records), issuance purpose (for providing insurer > medical use), residential area of applicant (Seoul > Honam province and Jeju), and number of copied documents (more documents gave a lower rate). The rate of unpreparedness differed significantly among the hospitals; suggesting that they may have followed their own conventional protocols rather than legal procedures in some cases. CONCLUSIONS: The study results showed that the level of compliance to the required legal procedure was high, but that problems occurred in assuring the safety of the medical information. A proper legislative approach is therefore required to balance the security of and access to medical information.
