정신과 의무기록 작성지침 개발 및 적용 후 입원의무기록의 질적 변화 비교 연구 = Development of Guideline for Psychiatric Medical Record and Quality Improvement Following Its Application

다국어 초록 (Multilingual Abstract)

Objectives: Medical records are used to store and communicate information about patient treatment. Nowadays, the problem oriented medical record (POMR) is the most frequently used method for medical records. The POMR has the advantage of evaluating the course of treatment；however, it is also criticized for focusing on just symptoms and signs. We propose new guidelines for psychiatric medical records based on a modified POMR.
Methods: We organized a research team of psychiatrists and psychiatric residents and, held weekly research meetings from March 2005 until May 2006. Under close psychiatric chart review, we found several problems with the POMR system, and based on these findings, we discussed various ways
of modifying it.
Results: We propose the following AMC psychiatric medical record guidelines：1) Problem lists should be classified into seven categories：psychiatric symptoms, function, risk, environment, special treatment, drug side effects, and medical problems. Additionally, treatment course should be
described accordingly. 2) Spontaneous reports by patients should be classified as subjective information, and any contents explored by the clinician, as objective information. Brief scales should be included for the quantitative description of symptoms. 3) Assessment should include symptom severity, treatment response, compliance, and suicidal or violent risk at evaluation point. 4) Specific management strategies such as rationale for dosage adjustment, detailed psychotherapeutic intervention, and psychoeducation should be described in the plan.
Conclusion: This is one of a few studies proposing guidelines for psychiatric medical records. The application of these will improve the quality of medical records and it is hoped that such guidelines will be used broadly.

다국어 초록 (Multilingual Abstract)

Objectives: Medical records are used to store and communicate information about patient treatment. Nowadays, the problem oriented medical record (POMR) is the most frequently used method for medical records. The POMR has the advantage of evaluating the course of treatment；however, it is also criticized for focusing on just symptoms and signs. We propose new guidelines for psychiatric medical records based on a modified POMR.
Methods: We organized a research team of psychiatrists and psychiatric residents and, held weekly research meetings from March 2005 until May 2006. Under close psychiatric chart review, we found several problems with the POMR system, and based on these findings, we discussed various ways
of modifying it.
Results: We propose the following AMC psychiatric medical record guidelines：1) Problem lists should be classified into seven categories：psychiatric symptoms, function, risk, environment, special treatment, drug side effects, and medical problems. Additionally, treatment course should be
described accordingly. 2) Spontaneous reports by patients should be classified as subjective information, and any contents explored by the clinician, as objective information. Brief scales should be included for the quantitative description of symptoms. 3) Assessment should include symptom severity, treatment response, compliance, and suicidal or violent risk at evaluation point. 4) Specific management strategies such as rationale for dosage adjustment, detailed psychotherapeutic intervention, and psychoeducation should be described in the plan.
Conclusion: This is one of a few studies proposing guidelines for psychiatric medical records. The application of these will improve the quality of medical records and it is hoped that such guidelines will be used broadly.

참고문헌 (Reference)

1 김진용, "정신증 환자의 증상과 기능에 대한 간략형 평가 척도의 타당도 및 신뢰도" 대한신경정신의학회 46 (46): 492-498, 2007

2 김창윤, "정신과 전자의무기록 프로그램 개발" 대한신경정신의학회 41 (41): 168-183, 2002

3 Donnelly WJ, "Viewpoint: patient-centered medical care requires a patient-centered medical record" 80 : 33-38, 2005

4 Lipp M, "Quality control in psychiatry and the problem oriented system" 11 : 355-365, 1973

5 Sandlow LJ, "Problem oriented medical records: self instruction for practitioners" Michael Reese Hospital and Medical Center 1978

6 Weed LL, "Medical records that guide and teach" 278 : 593-600, 1968

7 Sadock BJ, "Kaplan & Sadock's Synopsis of Psychiatry. 9th ed" Lippincott Williams & Wilkins 250-252, 2003

8 Sadock BJ, "Kaplan & Sadock's Synopsis of Psychiatry. 9th ed" Lippincott Williams & Wilkins 476-, 2003

9 Park CH, "Effect of electronic medical record on quality improvement of psychiatric inpatient medical record" 10 : 118-125, 2001