A Development Study of Common Clinical Document Forms for Traditional Korean Medicine Information Standardization

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문진석¹, 김정철¹, 박세욱², 고호연³, 김보영¹, 강병갑¹, 강경원¹, 최선미¹

1한국한의학연구원, ²천안충무한방병원 한방내과, ³세명대학교 한의과대학 내과학교실

Original Article

A Development Study of Common Clinical Document Forms for Traditional Korean Medicine Information Standardization

Jin-Seok Moon¹, Jeong-Cheol Kim¹, Sae-Wook Park², Ho-Yeon Ko³, Bo-Young Kim¹, Byoung-Gap Kang¹, Kyung-Won Kang¹, Sun-Mi Choi¹

1Korea Institute of Oriental Medicine

2Department of Oriental Internal Medicine, Cheonan Chungmu Hospital

3Department of Oriental Internal Medicine, Semyung University

Objectives: The clinical document forms, a format for collecting clinical data, is the most fundamental object of standardization. Doctors must have a mutual understanding of the clinical chart.

Methods: Clinical document forms were developed by investigating existing conditions in hospitals and conducting demand surveys, doing literature research, and seeking expert advice for the improvement of version 1.0. In addition, an organization of a network of 19 Oriental medical doctors and nurses, 190 patients, and users of collected and assessed data was formed to come up with version 2.0.

Results: The overall format was divided into different portions that the patient, nurse, and doctor must fill out, respectively. The patient’s section consists of demographic data, lifestyle details, history, and symptoms. The data to be supplied by the nurse include the patient’s vital signs and anthropometric parameters. As for the doctors, they are to supply data regarding the patient’s palpitation, the detailed symptoms of the patient’s head, ophthalmological and otorhinolaryngological symptoms (mouth), respiration, circulatory organ and chest conditions, digestive-organ conditions (thirst), neuropsychiatric conditions, reproductive system, musculoskeletal system, skin (depilation), etc.

Conclusions: Common clinical chart development is the prior question to Traditional Korean Medicine standardization.

A web-based clinical document format should be developed to support diagnosis and treatment, and furthermore EMR (electronic medical record system) and EHR (electronic health record) developed. Clinical information could be shared through a network of medical institutions and be useful Traditional Korean Medicine for evidence-based medicine.

Key Words : medical records, clinical document form, standardization, examination

접수：2008년 6월 30일 수정：2008년 12월 29일 채택：2009년 1월 5일

교신저자：최선미(Sun-Mi Choi)

(305-811) 대전광역시 유성구 엑스포로 483 한국한의학연구원 의료연구부

Tel：+82-42-868-9488, Fax：+82-42-863-9464, E-mail：moonstone2@kiom.re.kr

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Strongly disagree Disagree Neutral Agree Strongly agree

Difficulty 10(5.29) 65(34.39) 98(51.85) 16(8.47) 0(0)

Convenience 2(1.06) 14(7.45) 70(37.23) 76(40.43) 26(13.83)

Usefulness 0(0) 4(2.12) 37(19.58) 95(50.26) 53(28.04)

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Classification Items for Evaluation Strongly

disagree Disagree Neutral Agree Strongly agree

Composition side 설문지가 체계적으로 구성되어 있다. 2(10.53) 1(5.26) 5(26.32) 8(42.11) 3(15.79) 간호사, 환자, 한의사의 역할분담이 잘 되어 있다 0(0) 0(0) 4(21.05) 10(52.63) 5(26.32)

Contents side

진료에 적절한 내용이 포함되어 있다 0(0) 6(33.33) 4(22.22) 6(33.33) 2(11.11)

질문 항목이 많다 1(5.26) 5(26.32) 3(15.79) 7(36.84) 3(15.79)

기존 차트와의 차별화되지 않는다 0(0) 5(26.32) 5(26.32) 6(31.58) 3(15.79)

Efficient side

진료시간 단축시킬 수 있다 1(5.56) 2(11.11) 3(16.67) 11(61.11) 1(5.56)

환자대기시간을 효율적으로 활용할 수 있다 0(0) 2(10.53) 3(15.79) 10(52.63) 4(21.05) 한의사의 이중질문으로 인한 비효율적이다 3(15.79) 8(42.11) 1(5.26) 7(36.84) 0(0)

환자의 기본/증상정보의 획득에 용이하다 0(0) 0(0) 4(21.05) 11(57.89) 4(21.05)

Application side

변증진단에 많은 정보를 활용할 수 있다 1(5.26) 5(26.32) 5(26.32) 8(42.11) 0(0)

연구에 활용하기에 좋다 1(5.26) 3(15.79) 7(36.84) 4(26.32) 3(15.79)

질 높은 진료가 가능하다 0(0) 3(15.79) 8(42.11) 6(31.58) 2(10.53)

Table 2.

Question Time[minute] (Mean±SD)

Actual Time Patients to Fill Out Chart 13.28±5.72

Reasonable Time a Patient to Fill Out Chart 7.32± 2.94 Reasonable Time a Doctor to Fill Out Chart 8.63± 3.96 Table 3.

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