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Vol.29 No.3
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A Study on the Current Status and Tasks of Medical Records Management: Focused on Applying the KS X ISO 15489 to the Y Hospital

Journal of the Korean Society for Information Management / Journal of the Korean Society for Information Management, (P)1013-0799; (E)2586-2073
2012, v.29 no.3, pp.257-285
https://doi.org/10.3743/KOSIM.2012.29.3.257



& (2012). A Study on the Current Status and Tasks of Medical Records Management: Focused on Applying the KS X ISO 15489 to the Y Hospital. Journal of the Korean Society for Information Management, 29(3), 257-285, https://doi.org/10.3743/KOSIM.2012.29.3.257
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Abstract

As the electronic medical records systems (EMRs) are introduced into the hospitals in Korea and the needs of chief stakehoders of medical records are changed, the environments related to creating and managing medical records has been changed dynamically. At this moment it might be meaningful to examine medical records based on records management principles rather than information management principles. The purpose of this paper is to apply the KS X ISO 1549 standards, which covers the principles of records management, to hospital medical records management and assess the current quality of medical records management, and define a few tasks of improvement for hospitals. To achieve this goal, this study has performed following activities: Firstly, principles that could be applied to medical records management were prepared for each record management steps described in the standards, such as capture, registration, classification, storage, access, trace and disposition, and 22 principles were selected from those 7 steps of the record management. Secondly, the Y hospital, which is affiliated with a medical school in Seoul, was chosen to evaluate the current situation regarding medical records management. The department head of the medical records management team in Y hospital was interviewed and the present status was evaluated according to each principle. Thirdly, tasks for improvement were suggested, in such stages as access, trace and disposition. With this study as a cornerstone, useful implications are expected to be gathered from future studies that apply standards for metadata of records, management systems for records, and record management systems to medical record management in hospitals.

keywords
medical records, EMR(electronic medical records), records management assessment, health information manager(HIM), 병원기록, 전자의무기록관리, KS X ISO 15489, 기록관리평가, 의무기록사

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