본 책의 개정판이 나온 2013년 말 이후 2014년에는 세월호 사건과 모 요양병원의 화재사건, 2015년에는 메르스 사태와 모 의원의 일회용 주사기 재사용 사건이 우리나라 사회 전반에 안전의식을 일깨워준 한편, 정부의 요양병상 감소 정책과 맞물려 환자안전법의 통과, 요양병원 인력 및 시설 강화, 2주기 요양병원 인증기준 강화는 요양병원의 운영과 진료 환경을 점점 더 팍팍하게 만들고 있습니다. 그럼에도 불구하고 2000년대 중반 이후 증가 일로에 있는 요양병원의 숫자는 2016년 현재에도 완만하게나마 상승 곡선을 그리고 있고, 초고령화 사회를 코앞에 둔 우리나라에서 우리 요양병원의 역할은 그 중요성을 더해가고 있습니다.

3판의 주요 특징은 다음과 같습니다.

1. 거의 모든 장을 진료현장 중심의 실질적인 내용과 다양한 자료로 업데이트하였습니다.

2. 2016년 8월까지 개정되거나 예고된 법률 및 수가를 반영하였습니다.

3. 2017년부터 시행 예정인 2주기 요양병원 인증기준의 내용을 반영하였습니다.

4. 노인포괄평가 포켓카드를 추가하여 실제 환자평가 업무에 도움을 주고자 하였습니다.

 본 책의 부록으로 제공되는 노인포괄평가(CGA) 포켓카드는 우리나라 노인의학, 노인간호 서적 중 최초로 시도되는 아이템으로서, 노인환자를 주로 보는 의료인들이 노인환자 평가시에 반드시 알아야 할 핵심 내용들을 4개의 플라스틱 재질 카드에 담아, 주머니에 넣고 다니면서 현장에서 실무에 쉽게 적용할 수 있도록 기획하였습니다. 특히, 요양병원 간호사들은 매달 작성해야 하는 환자평가표와 간호평가 시에 본 포켓카드를 이용하면 여러 가지 다양한 도구들을 매번 들고 다니지 않으면서도 정확하고 신속하게 업무를 처리할 수 있을 것입니다. 또한 요양병원에 근무하지 않는 분이더라도 본 포켓카드를 통해서 노인환자 진찰 시에 무엇을 집중적으로 보아야 할지 단서를 얻을 수 있을 것입니다.

3판의 출간을 앞두고는 두려움보다는 설레임이 더 큽니다. 그 동안, 본 책에 많은 관심과

조언을 해 주신 헤아릴 수 없이 많은 분들께 머리를 숙이며, 특히 인쇄 전 마지막 순간까지전화와 문자, 이메일을 통해 저의 모든 요구사항을 활자화해주신 유현숙 편집디자이너께도 감사의 말씀을 올립니다.

벌써 남자의 느낌이 물씬 나기 시작하는 승민이와 세상에서 더 없이 착하고 예쁜 효경이,

그리고 늘 고맙고 미안한 아내 지선에게 사랑한다고 전합니다.

서늘한 바람이 반가운 2016년 10월 어느 날

가  혁

I 우리나라 요양병원에 대한 이해

1. 세계의 노인장기요양 의료서비스 현황 ···························02

2. 우리나라 요양병원의 현황 및 시설 요건 ······················14

3. 요양병원에는 어떤 환자가 입원하는가? ·························28

4. 요양병원에서 알아야 할 법적(法的) 문제들 ··················䞜

II 요양병원 수가,심사 체계

5. 요양병원 수가체계 장·단기 개편방향 ······························53

6. 요양병원 적정성 평가 ··························································67

7. 요양병원 보험청구 심사 ····················································77

8. 요양급여 삭감 및 현지조사 ···········································91

III 2주기요양병원 인증평가 대비

9. 2주기 요양병원 인증평가 개요 ····································108

10. 규정집 제작에서 조사 당일까지 ·······························117

11. 2주기 요양병원 인증평가 조사기준 별 핵심 체크 ······125

1) 안전보장활동 (환자안전‐직원안전‐시설안전포함) ·····126

2) 지속적 질 향상 및 환자안전 ·································135

3) 진료전달체계와 환자평가 ······································144

4) 환자 진료 ·····························································147

5) 의약품 관리 ·························································152

6) 환자권리 존중 ······················································160

7) 조직의 미션(사명) 및 운영 ···································163

8) 인적자원 관리 ······················································164

9) 감염 관리 ·····························································165

10) 시설환경 안전관리 ··············································173

11) 의료정보/의무기록 관리 ······································176

12. 2주기 요양병원 인증평가 시스템추적조사(ST),

리더십인터뷰(LI) 대비하기 ·········································178

IV 노인증후군

13. 노인 환자의 특성 및 비전형적 증상들 ····················194

14. 노인 증후군 ····························································204

15, 섬 망 ······································································209

16. 어지럼증 ·································································219

17. 낙 상 ······································································227

18. 욕 창 ······································································240

19. 요실금 ····································································254

20. 변실금 ····································································261

21. 변비 ·······································································264

22. 영양 장애와 탈수 ····················································271

23. 골다공증과 골절 ·····················································282

24. 우울증 ····································································290

25. 수면장애 ·································································297

26. 만성 근골격계 통증 ················································301

27. 근감소증과 노쇠 ·····················································315

V 치매환자 돌보기

28. 치매에 대한 접근법 ················································326

29. 치매의 이상행동심리증상 (BPSD) ···························340

30. 치매 환자의 부적절한 성적 행동(ISB) ···················349

31. 치매 예방을 위한 PASCAL 생활수칙 ······················353

32. 치매 노인들을 위한 활동프로그램 ···························355

VI 젊은이와 다른 노인성 질환들의 특성

33. 노인의 고혈압 ·························································369

34. 노인의 당뇨병 ·························································376

35. 뇌졸중 ····································································382

36. 만성 폐쇄성 폐질환(COPD): 만성기관지염, 폐기종 ·····386

37. 골관절염 ·································································392

38. 진전(tremor)과 파킨슨병 ········································395

39. 노인에서 흔한 감염성 질환들 (폐렴, 폐결핵, 요로 감염)············403

40. 노인에서 흔한 피부질환들 ·······································412

VII노인환자 진료의 원칙

41. 노인환자의 진찰 요령 ·············································436

42. 요양병원에서의 노인포괄평가(CGA) ·························447

43. 신경학적 검사 ·························································470

44. 노인 환자의 임상 검사 결과 해석하기 ···················489

45. 노인 환자의 원활한 외래 진료를 위한 지침 ············493

46. 노인 약물 처방의 원칙 ···········································498

47. 노인에서 항생제 사용의 원칙 ································509

48. 다빈도 질환 처방 및 간단한 수기 ···························517

49. 보완대체요법에 관한 질문을 받을 때 -

근거중심의학에 기반한 권고 ····································537

VIII 요양병원 입원환자 진료의 팁

50. 요양병원 의사 되기 ················································551

51. 요양원 촉탁 의사 되기 ···········································555

52. 보호자 면담을 통한 입원 결정 과정 ························575

53. 요양병원 입원 시 의사의 의무 기록 ························579

54. 인공 튜브 관리 (L-tube, G-tube, Foley,

인공항문, T-tube) ···················································588

55. 보라색 소변 증후군 (Purple Urine Syndrome; PUS)·············602

56. 요양병원에서의 CT, MRI 촬영 ······························608

57. 다른 병원에 진료 의뢰하기 ·····································611

IX 요양병원 간호사 업무

58. 요양병원 간호사의 하루 일과 ··································615

59. 환자 입원시 병동 간호사가 체크할 사항들 ··············624

60. 간호기록지 작성 요령 ·············································631

61. 환자평가표 작성요령 ···············································639

62. 동영상을 활용한 일상생활수행능력 평가 ·················667

63. 구강 관리 ·······························································673

64. 간병인에 대한 교육 및 감독 ···································680

65. 의사에게 환자 상태 리포트 하기 ···························698

X 요양병원에서 만나는 어려운 상황들

66. 환자에게 발생하는 여러 복잡한 상황들에 대한 대처 ···704

67. 신체 보호대의 적용 및 관리 ···································707

68. 요양병원에서의 심폐소생술 ·····································713

69. 말기 환자 관리의 원칙 ···········································719

70. 요양병원에서의 의료 윤리와 연명의료 중지 ············728

71. 사전의료 의향서(AD)와 연명의료계획서(POLST) ······736

72. 말기암 환자 통증 관리 ···········································758

73. 비암성 말기환자 증상 관리 ·····································765

XI 요양병원에서 흔히 작성하는 서류들

74. 사망진단서(시체검안서) 작성 요령 ···························780

75. 각종 진단서, 소견서, 신청서 작성요령 ··················787

76. 노인장기요양보험제도의 이해와 의사소견서

작성요령 ·································································806

77. 생애전환기 건강진단 사후상담의사 매뉴얼 ··············834

참고문헌 ····················································································885

부록 1. 요양병원 직원들이 자주 하는 질문들(FAQ) ·······911

부록 2. 인천은혜병원 2주기인증대비 규정집 ·················927

부록 3. 인천은혜병원 식사처방지침서와

임상영양관리지침서 및 급식관리지침서 ·················1097

I, 식사처방 지침서(치료식 식단 작성 포함) ·········1098

II. 임상영양관리 지침서 ····································1110

III. 급식관리 지침서 ·········································1122

NDEX··················································································1139

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