한의원에서 사용 중인 종이차트의 항목 현황 분석 연구

Abstract

Objective The purpose of the study is to collect current paper charts used (in clinical practice of Korean Medicine Clinics) and analyze the diagnosis items included in the charts to study which items should be included in future electronic charts. Methods Paper charts were randomly collected from 74 Korean Medicine Clinics located in and near Jeonju region from April to June, 2017 and analysis on specific information of the charts including chief complaint, medical history, inspection, listening and smelling examination, inquiry, palpation, constitution, and pictures was conducted. Results The study showed specific items of paper charts included a considerable amount of information needed from the Korean Medicine doctor perspective. Items related with food intake (72%), feces and urine (72%), sleep (69%), perspiration (51 %), inquiry or pulse diagnosis of gynecological symptoms (73%), pictures of the front of the whole body (68%) and back of the whole body (65%) were included in paper charts of more than half of the studied subjects which shows these were significant items. Conclusion Paper charts include items that the user considers what is important in diagnosis thus it is important to apprehend which items are included in the chart. Based on the study, some specific items were included in more than half of the paper charts which shows these are considered as significant items. Therefore, in the process of developing standardized electronic charts, developing the items that needs to be included in the electronic charts should be carried out simultaneously.

Keywords

• Paper chart
• Current status of items
• Standardized electronic chart