| 한국형 성인 뇌전증 공통 데이터 요소 기반 외래 진료 전자건강기록 서식 활용에 대한 실용적 권고 |
| 이동원1, 구용서2, 손영민3, 이서영4, 김헌민5, 대한뇌전증학회 연구위원회 |
1강동성심병원 신경과
2서울아산병원 신경과
3삼성서울병원 신경과
4명지병원 신경과
5분당서울대학교병원 소아청소년과 |
| Practical Recommendations for Electronic Health Record Templates in Adult Epilepsy Outpatient Care Based on Korean Epilepsy Common Data Elements |
| Dongwon Lee MD, MS1, Yong Seo Koo MD, PhD2, Young-Min Shon MD, PhD3, Seo-Young Lee MD, PhD4, Hunmin Kim MD, PhD5, On Behalf of the Research Committee of the Korean Epilepsy Society |
1Department of Neurology, Kangdong Sacred Heart Hospital, Seoul, Korea
2Department of Neurology, Asan Medical Center, Seoul, Korea
3Department of Neurology, Samsung Medical Center, Seoul, Korea
4Department of Neurology, Myongji Hospital, Goyang, Korea
5Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea |
Corresponding Author:
Yong Seo Koo ,Tel: +82-2-3010-5920, Fax: +82-2-474-4691, Email: yo904@naver.com
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Received: March 31, 2026 Revised: April 23, 2026 Accepted: April 23, 2026 Published online: July 1, 2026 |
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| Abstract |
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Epilepsy is characterized by transient events rarely witnessed during outpatient visits, making thorough history-taking essential for clinical decision-making. In Korea, extremely limited visit durations amplify practice variation and increase the risk of missing safetycritical information. This article presents practical recommendations for the use of electronic health record templates in adult epilepsy outpatient care based on Korean epilepsy common data elements. These recommendations were developed from the Korean epilepsy common data elements consensus study and guidebook, together with relevant international literature, standardized classification systems, and expert discussion. The recommended template is structured into three visit types: initial evaluation, routine follow-up, and periodic reassessment. For the initial evaluation, priorities include reconstructing the index event, identifying modifiable precipitants, reviewing antiseizure medication history, assessing comorbidities, and addressing safety issues such as driving risk. Follow-up documentation should focus on seizure control, interval changes, treatment response, adverse effects, potential triggers, and the clinical rationale for treatment maintenance or modification. Periodic reassessment is recommended when the clinical course is unexpected, diagnostic uncertainty persists, or treatment resistance is suspected. Use of a standardized Korean epilepsy common data element-based template may improve consistency of outpatient documentation, support continuity of care, and provide a practical framework for clinical decision making. Wider implementation through resources provided by the Korean Epilepsy Society may also facilitate multicenter research and quality improvement. |
| Key Words:
Epilepsy | Outpatients | Medical history taking | Common data elements | Reference standards |
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