ABSTRACT

Objective : This study was conducted to be used as an essential resource for standardizing a future medical terminology framework by analyzing the current status of the Electronic Medical Record (EMR) system and medical terminology used in health-care institutes where occupational therapists are employed. Methods : A total of 121 health-care institutes where occupational therapists are employed completed surveys regarding the current status of occupational therapy related to medical terminology use. This study was divided into two categories performed individually based on the use of the EMR system. The data were analyzed using an SPSS multiple response module. Results : Among the 121 health-care institutions, 102 institutions use the EMR system, which is a rate of 84.3%. Treatment plans are already recorded in the system, and the progress notes can be edited by pulling out the recorded data. More than 60.0% of the institutions expressed limitations in using the occupational therapy treatment terminology of the system. In addition, 85.1% indicated the necessity of standardizing medical terminology, and 74.5% showed a strong willingness to apply standardized terminology if the Korea Association of Occupational Therapists (KAOT) approves an official standardized medical terminology framework. Conclusion : The standardization of Korean occupational therapy medical terminology needs to be promoted by incorporating the International Classification of Health Intervention (ICHI), Current Procedural Terminology (CPT) code, and Occupational Therapy Practice Framework (OTPF) terminology.