PURPOSE: The purposes of this study were to investigate medical records and to develop care records for management of patients with chest pain in the emergency department. METHOD: Retrospective review of the 42 medical chart of patients presented to the emergency department with chest pain were used. The collected data were analyzed with a frequency of items in the medical records. RESULTS: In a frequency analysis of recorded items for doctors' chest pain assessment during history taking, the history/risk factors was the highest rank. The following ranks were 'commenced with when/ timing, extra symptoms, place, nature, stay/ radiate, alleviate/aggravate, intensity' in sequence. In a frequency of recorded items in nurse's progress notes according to nursing actions, the 'checking/monitoring' was the highest rank. The following ranks were 'performing, administering/injecting, referring/ arranging, testing, preparing/catheterizing, teaching/informing' in sequence. Chest pain care records for the emergency department was designed, based upon data analysis and literature review. CONCLUSION: The designed records can be a rapid and effective approach tool for assessment and recording of patients with chest pain. Further research is necessary for evaluating the designed chest pain care records.
Chest Pain* ; Emergencies* ; Emergency Service, Hospital* ; Humans ; Medical Records* ; Nursing ; Nursing Records ; Retrospective Studies ; Statistics as Topic ; Thorax*

OBJECTIVES: This study intended to identify the staff nurse's activity in general hospital, where its Hospital Information System is well established and Electronic Nursing Record System was being used for 2 years. METHODS: Procedure was done with the following steps; In the first step, nursing activity time was analysed by checklist, which 28 nurses filled out by themselves. The group interview was followed. RESULTS: During the day shift, the direct nursing activities took 37.04%, indirect nursing 40.74%, ward management 18.52% and personal time 3.70% respectively. In evening shift, nurses used 29.41% on direct nursing, 45.10% on indirect nursing, 19.61% on ward management and 5.88% on personal time. In night shift, direct nursing took 17.91%, indirect nursing 46.27%, ward management 17.91% and personal time 11.98%. The group interview reported the differences in nursing activities which recognized by the included staff nurses after the introduction of ENR; speed and convenience in working, the correctness and speed of recording, reduction of indirect nursing time including recording time and increase of direct nursing time and patient education. CONCLUSIONS: The introduction of HIS including ENR system was verified to be effective on improvement of nursing quality, by bringing reduction of indirect nursing time and increase of direct nursing time.
Checklist ; Electronics ; Electrons ; Hospital Information Systems ; Hospitals, General ; Humans ; Interviews as Topic ; Nursing Records ; Resin Cements

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

Referring to XDS-I and RIM of ebXML, we have built a registry system for electronic medical records sharing which is introduced, in this paper.
Hospital Information Systems ; Humans ; Information Storage and Retrieval ; methods ; Medical Record Linkage ; methods ; Medical Records Systems, Computerized ; Multimedia ; Radiology Information Systems ; Software ; User-Computer Interface

PURPOSE: To evaluate superiority of a night float (NF) system in comparison to a traditional night on-call (NO) system for surgical residents at a single institution in terms of efficacy, safety, and satisfaction. METHODS: A NF system was implemented from March to September 2017 and big data analysis from electronic medical records was performed for all patients admitted for surgery or contacted from the emergency room (ER). Parameters including vital signs, mortality, and morbidity rates, as well as promptness of response to ER calls, were compared against a comparable period (March to September 2016) during which a NO system was in effect. A survey was also performed for physicians and nurses who had experienced both systems. RESULTS: A total of 150,000 clinical data were analyzed. Under the NO and NF systems, a total of 3,900 and 3,726 patients were admitted for surgery. Mortality rates were similar but postoperative bleeding was significantly higher in the NO system (0.5% vs. 0.2%, P = 0.031). From the 1,462 and 1,354 patients under the NO and NF systems respectively, that required surgical consultation from the ER, the time to response was significantly shorter in the NF system (54.5 ± 70.7 minutes vs. 66.8 ± 83.8 minutes, P < 0.001). Both physicians (90.4%) and nurses (91.4%) agreed that the NF system was more beneficial. CONCLUSION: This is the first report of a NF system using big data analysis in Korea, and potential benefits of this new system were observed in both ward and ER patient management.
Electronic Health Records ; Emergency Service, Hospital ; Hemorrhage ; Humans ; Internship and Residency ; Korea ; Medical Staff ; Mortality ; Statistics as Topic ; Vital Signs

This paper presents a method based on NLP to realize structuralization of digestive endoscopy reports. The method is taking advantage of existing NLP's processing technologies and introducing minimal standard terminology (MST) to transform a narrative gastroscopy report into the structuralization report based on MST, whose accuracy rate is 92.3%.
Endoscopy, Gastrointestinal ; methods ; Forms and Records Control ; Medical Records Systems, Computerized ; Terminology as Topic ; Vocabulary, Controlled

AIMTo improve workflow and usability by introduction of a new electronic patient record (EPR) and database.

METHODSEstablishment of an EPR based on open source technology (MySQL database and PHP scripting language) in a tertiary care andrology center at a university clinic. Workflow analysis, a benchmark comparing the two systems and a survey for usability and ergonomics were carried out.

RESULTSWorkflow optimizations (electronic ordering of laboratory analysis, elimination of transcription steps and automated referral letters) and the decrease in time required for data entry per patient to 71%+/-27%, P<0.05, lead to a workload reduction. The benchmark showed a significant performance increase (highest with starting the respective system: 1.3+/-0.2 s vs. 11.1+/-0.2 s, mean+/-SD). In the survey, users rated the new system at least two ranks higher over its predecessor (P<0.01) in all sub-areas.

CONCLUSIONWith further improvements, today's EPR can evolve to substitute paper records, saving time (and possibly costs), supporting user satisfaction and expanding the basis for scientific evaluation when more data is electronically available. Newly introduced systems should be versatile, adaptable for users, and workflow-oriented to yield the highest benefit. If ready-made software is purchased, customization should be implemented during rollout.

Andrology ; organization & administration ; Benchmarking ; Databases as Topic ; standards ; Ergonomics ; Germany ; Hospitals, University ; Humans ; Male ; Medical Records Systems, Computerized ; standards ; Outpatient Clinics, Hospital ; organization & administration ; Systems Analysis ; User-Computer Interface ; Work Simplification ; Workload ; statistics & numerical data

OBJECTIVE: This study was conducted to evaluate the concordance between the underlying causes of death (UCOD) on the death certificates written by three emergency physicians (EPs). We investigated errors on the death certificates committed by each EP.METHODS: This study included 106 patients issued a death certificate in the emergency department of an academic hospital. Three EPs reviewed the medical records retrospectively and completed 106 death certificates independently. The selection of the UCOD on the death certificates by each EP (EP-UCOD) was based on the general principle or selection rules. The gold standard UCOD (GS-UCOD) was determined for each patient by unanimous consent between three EPs. We also compared between the EP-UCOD and the GS-UCOD. In addition, we compared between UCODs of three EPs. The errors on the death certificates were investigated by each EP.RESULTS: The rates of concordance between EP-UCOD and the GS-UCOD were 86%, 81%, and 67% for EP-A, EP-B, and EP-C, respectively. The concordance rates between EP-A and EP-B were the highest overall percent agreement (0.783), and those between EP-A and EP-C were the lowest overall percent agreement (0.651). Although each EP had differences in the errors they committed, none of them listed the mode of dying as UCOD.CONCLUSION: This study confirmed that each EP wrote death certificates indicating different causes of death for the same decedents; however, the three EPs made fewer errors on the patients’ death certificates compared with those reported in previous studies.
Cause of Death ; Death Certificates ; Emergencies ; Emergency Medicine ; Emergency Service, Hospital ; Humans ; Medical Records ; Mortality ; Retrospective Studies

OBJECTIVES: This study was performed to evaluate the occupational relationship on 190 cases of cancer selected out of 622 cases of cancer registered in two university hospitals from January 1, 1996 to December 31, 1997. METHODS: The selection criteria was for the patient to be more than 40 years old with lung, liver, urinary bladder, nasal cavity and skin cancer or leukemia. We reviewed the medical records to update the missing data and occupational histories. Telephone interviews were used to obtain complete occupational histories on the subjects. RESULTS: The sites of cancer in the order of relative frequency was lung (51.0%), followed by liver (32.9%), urinary bladder (14.1%) and skin (2.0%) in male, liver (41.5%), followed by lung (31.7%), skin (19.5%) and urinary bladder (7.3%) in female. The occupational histories of 190 cases with suspected cancer-causing occupations were recorded 5.8% on the doctor's medical records and 33.2% on the nursing records. The response rates of the telephone interviews were 87.4%. The distribution of occupation according to the telephone interviews was farmer (47.7%), office worker (16.1%), salesman (12.8%), production worker (6.7%), simple laborer (3.4%) and unknown (13.4%) in male, housewife (63.4%), farmer (17.1%), saleswoman (9.8%) and unknown (9.8%) in female. And there were two cases of suspected occupational relationships in the lung cancer cases. CONCLUSIONS: We could not discover definite cases of occupational cancer but found out two cases of suspected occupational relationships. Occupational cancer is likely to increase in the near future, so the efforts to detect occupational relationships with cancer should be continued.
Adult ; Female ; Hospitals, University* ; Humans ; Interviews as Topic ; Leukemia ; Liver ; Lung ; Lung Neoplasms ; Male ; Medical Records ; Nasal Cavity ; Nursing Records ; Occupations ; Patient Selection ; Skin ; Skin Neoplasms ; Urinary Bladder

PURPOSE: This study was performed to evaluate factors affecting the decision to operate in orbital fracture patients. METHODS: This study included 396 orbital fracture patients who visited an urban tertiary teaching hospital emergency room from January 1, 2002 to December 31, 2005. We reviewed medical records of the patients. Data collected included a patient's sex, age, mechanism of trauma, wall fractures, associated other facial bone fracture, visual disturbance and ocular motility disturbance. The Chi-square test, t-test were applied in order to evaluate the factors associated with the decision to operate in orbital fracture cases. Multinomial logistic regression was applied to those factors which achieved significance in Chi-square test. RESULTS: As seen in other studies, orbital fractures were frequent in young males ages 10 through 40. The most common cause of orbital fractures was violence (41.0%). In the Chi-square test, medial, lateral and inferior wall fractures; skull vault fracture; nasal septum fracture; diplopia; ocular motor dysfunction; and fractures involving more than two walls were found to be statistically significant in the decision to operate compared to other factors. Diplopia, lateral wall fracture, ocular motor dysfunction, skull vault fracture, and inferior wall fracture were confirmed by multinominal logistic regression analysis as positive predictors of a decision to operate in orbital fracture. CONCLUSION: Orbital wall fracture patient with diplopia, lateral or inferior wall fracture, ocular motor dysfunction, and skull vault fracture are likely to result in surgical intervention.
Diplopia ; Emergency Service, Hospital ; Facial Bones ; Forecasting ; Hospitals, Teaching ; Humans ; Logistic Models ; Male ; Medical Records ; Nasal Septum ; Orbit* ; Orbital Fractures* ; Patient Education as Topic ; Skull ; Violence