Evaluation of unpreparedness when issuing copies of medical records in tertiary referral hospitals

Myong Mo Moon, Myung Geun Kang, Sun Won Seo, Woo Sung Park, Yoon Kim, Sung Soo Kim, Eun Mi Choi, Jong Park, Il Soon Park

Research output: Contribution to journalArticleResearchpeer-review

Abstract

Objectives: As a baseline study to aid in the development of proper policy, we investigated the current condition of unpre-paredness of documents required when issuing copies of medical records and related factors. Methods: The study was com-prised of 7, 203 cases in which copies of medical records were issued from July 1st, 2007 through June 30th, 2008 to 5 tertiary referral hospitals. Data from these hospitals was collected using their established electronic databases and included study variables such as unpreparedness of the required documents as a dependent variable and putative covariates. Results: The rate of unpreparedness of required documents was 14.9%. Multiple logistic regression analysis revealed the following factors as being related to the high rate of unpreparedness: patient age (older patients had a higher rate), issuance channels (on ad-mission > via out-patient clinic), type of applicant (others such as family members > for oneself > insurers), type of original medical record (utilization records on admission > other records), issuance purpose (for providing insurer > medical use), residential area of applicant (Seoul > Honam province and Jeju), and number of copied documents (more documents gave a lower rate). The rate of unpreparedness differed significantly among the hospitals; suggesting that they may have followed their own conventional protocols rather than legal procedures in some cases. Conclusions: The study results showed that the level of compliance to the required legal procedure was high, but that problems occurred in assuring the safety of the medical information. A proper legislative approach is therefore required to balance the security of and access to medical information.

Original languageEnglish
Pages (from-to)120-132
Number of pages13
JournalHealthcare Informatics Research
Volume16
Issue number2
DOIs
StatePublished - 1 Dec 2010

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Tertiary Care Centers
Medical Records
Insurance Carriers
Access to Information
Policy Making
Regression analysis
Logistics
Outpatients
Logistic Models
Regression Analysis
Databases
Safety

Keywords

  • Medical information
  • Medical records
  • Referral hospitals
  • Unpreparedness required documents

Cite this

Moon, Myong Mo ; Kang, Myung Geun ; Seo, Sun Won ; Park, Woo Sung ; Kim, Yoon ; Kim, Sung Soo ; Choi, Eun Mi ; Park, Jong ; Park, Il Soon. / Evaluation of unpreparedness when issuing copies of medical records in tertiary referral hospitals. In: Healthcare Informatics Research. 2010 ; Vol. 16, No. 2. pp. 120-132.
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Evaluation of unpreparedness when issuing copies of medical records in tertiary referral hospitals. / Moon, Myong Mo; Kang, Myung Geun; Seo, Sun Won; Park, Woo Sung; Kim, Yoon; Kim, Sung Soo; Choi, Eun Mi; Park, Jong; Park, Il Soon.

In: Healthcare Informatics Research, Vol. 16, No. 2, 01.12.2010, p. 120-132.

Research output: Contribution to journalArticleResearchpeer-review

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AU - Choi, Eun Mi

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AU - Park, Il Soon

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N2 - Objectives: As a baseline study to aid in the development of proper policy, we investigated the current condition of unpre-paredness of documents required when issuing copies of medical records and related factors. Methods: The study was com-prised of 7, 203 cases in which copies of medical records were issued from July 1st, 2007 through June 30th, 2008 to 5 tertiary referral hospitals. Data from these hospitals was collected using their established electronic databases and included study variables such as unpreparedness of the required documents as a dependent variable and putative covariates. Results: The rate of unpreparedness of required documents was 14.9%. Multiple logistic regression analysis revealed the following factors as being related to the high rate of unpreparedness: patient age (older patients had a higher rate), issuance channels (on ad-mission > via out-patient clinic), type of applicant (others such as family members > for oneself > insurers), type of original medical record (utilization records on admission > other records), issuance purpose (for providing insurer > medical use), residential area of applicant (Seoul > Honam province and Jeju), and number of copied documents (more documents gave a lower rate). The rate of unpreparedness differed significantly among the hospitals; suggesting that they may have followed their own conventional protocols rather than legal procedures in some cases. Conclusions: The study results showed that the level of compliance to the required legal procedure was high, but that problems occurred in assuring the safety of the medical information. A proper legislative approach is therefore required to balance the security of and access to medical information.

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