J Korean Soc Med Inform.
1997 Dec;3(2):91-98.
Review of Core Elements used in Medical Records and their Definitions for Medical Informatics Standard
Abstract
- We present the basic standard framework for medical record. Standard is important for medical data communication and information sharing between hospitals. In first stage, to check the current status of variety of medical record formats, we gathered all medical record formats used in BO general hospitals. The results showed different sheet names used for the same medical record sheet. The items used in each sheet were counted to check how many hospitals were using them. The frequently used item list will be helpful to design medical record formats in new hospitals. Next we reviewed the core elements of discharge abstract. Finally we defined minimal core data for discharge abstract and provided their application criteria.
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