1. Introduction
As the computer technology like internet has been developing, many medical images and data related in medical is being applied to medical service for a diverse range of service such as diagnosis, management and treatment. A format of medical information and the standardization of the process of exchange are needed to control to enormous amount of information and exchange it.
1. Identifying Information
A. Name: Conchita Morales
B. Age: 35
C. Sex: Female
D. Job: Research chemist
2. Conceptualization
Axis IV based on DSM-V-TR
Axis I: 300.21 Panic Disorder With Agoraphobia
Axis II: none
Axis III: Past experience of anti-anxiety medication
Axis IV: job promotion offer from boss recently
Axis V: GAF (61~
Protection)
3. 진단검사
CBC count
ABGA
일반화학검사
CT판독(복부 및 골반)
뇌파 검사실
CT 판독(경부)
Abdomen : supine
CT 판독(흉부)
Chest : Pa
4. 기록
진 단 기 록 지
Admission note
Discharge Summary
BST
I/O
V/S
낙상 위험 사정 도구
욕창 위험 사정 도구
OPERATION RECORD
Nurse Record
PROGRESS NOTE
5. Medication
약리작용
Medical Information System) . For government supervises citizen’s health information more than systematic and effective and this relieve patient’s discomfort about medical documents.
That is, All citizen’s medical information is collected in KMIS. And as KMIS supervise the information, KMIS reduce having patients, hospital, and government discomfort and effectively manage the informatio
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