Pattern of changes in hospital morbidity rates, calculated from medical records were presented for the inpatients population, who were admitted to Severance Hospital and were discharged from March 1, 1970 to February 28, 1978. Diseases were classified according to the International Classification of Diseases and Injuries of the World Health Organization. Infectious diseases, such as bacillary and amebic dysenteries, parasitic diseases and respiratory tuberculosis have decreased, and non-infectious diseases, such as malignant neoplasms, congenital anomalies, diabetes mellitus, and hypertensive heart diseases have increased.
Hospital Records ; Human ; Korea ; Morbidity*

With the electronic medical records information system as the core of hospital information platform design, this paper introduces the design of the system which is structured for electronic medical records, and the advantage and effectiveness is also introduced. From the aspects of the concept, system framework, data integration, right frame and safety control, identity index and a clinical pathway, etc, the paper introduces the basic idea and process of the hospital information platform design, with the hospital recording electronic medical records as the core.
Electronic Health Records ; Hospital Information Systems ; Medical Records Systems, Computerized

Vitreous opacity is one of the common indication for pars plana vitrectomy to restore clarity of the optical pathway of the eye. We reviewed the hospital records of 82 patients who underwent pars plana vitrectomy for vitreous opacity at Yeungnam University Hospital from July 1, 1983 to February 28, 1987 and analyzed the functional results. Causes of vitreous opacity were traumatic vitreous hemorrhage in 23.5%, that with retinal branch vein occlusion in 22.3%, endoph-thalmitis in 21.2% and vitreous hemorrhage with proliferative diabetic retinopathy in 10.5%. Visual improvement was noted in 64.7% and no change in 21.2% while 14.1% worsened following the operation. Vitrectomy was found to be more beneficial to vitreous hemorrhage in Terson's syndrome and that with retinal branch vein occlusion.
Diabetic Retinopathy ; Hospital Records ; Humans ; Retinaldehyde ; Veins ; Vitrectomy* ; Vitreous Hemorrhage

OBJECTIVE: This study aims at investigating the incidence, clinical nature and associated clinical characteristics of the clozapine-induced fever. METHODS: Retrospective review of hospital records was performed for 56 inpatients who had started to take clozapine and stayed at the hospital for four or more weeks after the initiation of clozapine treatment. RESULTS AND CONCLUSION: Clozapine-induced fever was developed in 31% of the patients. The mean peak temperature was 39degrees C and the mean duration of the fever was 3 days. Fever was developed average of 11 days after the initiation of clozapine treatment. All the patients were recovered without discontinuation of clozapine. Demographic variables, the clinical response to clozapine, other drugs administered with clozapine, and the presence of other adverse effects of clozapine were not associated with the clozapine-induced fever.
Clozapine* ; Fever* ; Hospital Records ; Humans ; Incidence* ; Inpatients ; Retrospective Studies ; Schizophrenia

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.
Automation* ; Hospital Information Systems ; Medical Records* ; Surveys and Questionnaires

Recently there has been attempts to develop hospital information system including order communicating system, patient tracing system, tumor registry system, office automation system and picture archiving and communication system(PACS). The authors devloped a practical system that was operated via order communication system of Yeungnam University Hospital. The system provided us the 'speed, accuracy, reliability, retention, economy and wide applicability through practical test. So we believed that this system would be one of standard computerized programs in radiation oncology practice and providing widely usable data for clinical statistics, medical record, tumor registry system and clinical researches.
Hospital Information Systems ; Humans ; Medical Records ; Office Automation ; Radiation Oncology*

BACKGROUND: We investigated changes in the International Normalized Ratio (INR) and its measurement interval in patients with thromboembolic events who were treated by low intensity anticoagulation therapy after isolated mechanical aortic valve replacement. MATERIALS AND METHODS: Seventy-seven patients who underwent surgery from June 1990 to September 2006 were enrolled in the study and observed until August 2008. The patients were followed up at 4~8 week intervals and their warfarin (Coumadin)(R) dosage was adjusted aiming for a target range of INR 1.5~2.5. The rate of thromboembolic events was obtained. Changes in the mean INR and INR measurement interval were comparatively analyzed between the normal group (event free group, N=52) who had no anticoagulation-related complications and the thromboembolic group (N=10). Hospital records were reviewed retrospectively. RESULTS: The observation period was 666.75 patient-years. Thromboembolic events occurred in 10 patients. The linearized occurrence rate of thromboembolism was 1.50%/patient-years. Actuarial thromboembolism-free rates were 97.10+/-2.02% at 5 years, 84.30+/-5.22% at 10 years, and 67.44+/-12.14% at 15 years. The percentages of INR within the target range and mean INR were not statistically significantly different for the normal and thromboembolic groups. However, the mean INR during the segmented period just before the events showed a significantly lower level in the thromboembolic group (during a 4 month period: normal group, 1.86+/-0.14 vs. thromboembolic group, 1.50+/-0.28, p<0.001). The mean intervals of INR measurement during the whole observation period showed no significant differences between groups, but in the segmented period just before the events, the interval was significantly longer in thromboembolic group (during a 6 month period: normal group, 49.04+/-9.47 days vs. thromboembolic group, 65.89+/-44.88 days, p<0.01). CONCLUSION: To prevent the occurrence of thromboembolic events in patients who receive isolated aortic valve replacement and low intensity anticoagulation therapy, we suggest that it would be safe to maintain an INR level above 1.8 and to measure the INR at least every 7~8 weeks.
Aortic Valve ; Hospital Records ; Humans ; International Normalized Ratio ; Thromboembolism ; Warfarin

BACKGROUND: In accordance with the increase of the old age group, the incidence of actinic keratosis (AK) also increases. But there has been no comparative study between the clinical and histopathological margins. OBJECTIVE: The purpose of this study was to compare the clinical margin with histopathological margin of AK in Korean patients. METHOD: All cases of AK confirmed by biopsy from February 1, 1993 to May 31, 2003 were reviewed by hospital records and biopsy slides. Total 50 AK cases excised with 2mm surgical free margin were selected and analyzed clinically and histopathologically. RESULTS: 1. Histopathologically, hypertrophic type of AK was noted in 18 cases (36%), atrophic type in 8 cases (16%), bowenoid type in 5 cases (10%), acantholytic type in 3 cases (6%), pigmented type in 2 cases (4%), and combined form of hypertrophic and atrophic types was noted in 7 cases (14%), combined form of atrophic and pigmented types in 5 cases (10%), and combined form of acantholytic and pigmented types in 2 cases (4%). 2. The total proportion of surgical margin involvement was 44% (22/50): hypertrophic type in 55.5% (10/18), atrophic type in 87.5% (7/8), bowenoid type in 20% (1/5), acantholytic type in 33.3% (1/3), pigmented type in 0% (0/2), combined form of hypertrophic and atrophic types in 28.5% (2/7), combined form of atrophic and pigmented types in 20% (1/5), and combined form of acantholytic and pigmented types in 0% (0/2). CONCLUSION: In 50 cases of AK excised with 2mm surgical free margin, 22 cases (44%) showed tumor cells on the surgical margin. Especially hypertrophic and atrophic types showed significant proportion of marginal involvement. In respect that hypertrophic and atrophic types are more common than other subtypes of AK in Korean patients, skin biopsy and check-up for surgical margin are recommended in all AK.
Actins* ; Biopsy ; Hospital Records ; Humans ; Incidence ; Keratosis, Actinic* ; Skin

This study aimed to analyze the errors and their causes in inappropriately completed death certificates, and to suggest improvement measures. The death certificate is an important medical document that proves the cause and manner of death. However, a death certificate is not as valuable as a medical document, since many death certificates are inappropriately completed and thus provide inaccurate information. We reviewed 307 death certificates issued by the Emergency Room of Chung Nam National University Hospital between January 1, 2015, and November 31, 2016, and compared their details with the cause and manner of death in the patients' medical records. Among various errors, the most common was “omission of other significant information not related to the cause of death” (184 cases). On 29 death certificates, the mechanism of death was recorded instead of the cause of death. When comparing death certificates and medical records, discrepancies in the cause and manner of death were found in 13 (4.2%) and 17 (5.5%) cases respectively. Although the contents of a death certificate may vary according to a physician's point of view, multiple errors on death certificates should be avoided, and we suggest necessary improvement measures.
Cause of Death ; Death Certificates* ; Emergencies* ; Emergency Service, Hospital* ; Medical Records

The doctor's order system of electronic anamnesis is the bridge between HIS system and a much better service, especially when the HIS system is focused on its billing function. In practice, we continuously perfect and better the interface and functions of medical advising inputs to effectively standardize doctors' orders and lessen mistakes. It can also enhance working efficiency, and set a valid platform for medical billing management, rationalized drug use management, antibiotic classification management, clinical application, etc.
Hospital Information Systems ; Medical Records Systems, Computerized ; Physician's Role