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Effect of Education and Written Feedback on the Quantity and Quality of Documenting Patients' Records in a General Teaching Hospital: An Action Research Study
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Bahar Moasses-Ghafari    1, Asefeh Abbaszadeh2 , Khaled Rahmani3 |
1- Assistant Professor of Nuclear Medicine, School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran , baharmoassesghafari@gmail.com
2- Assistant Professor of Infectious Diseases, School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran.
3- Associate Professor of Epidemiology, Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran |
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Abstract: (361 Views) |
Background and Aim: Numerous studies conducted in Iran have shown that the quality of documentation of medical records by physicians and medical staff is not very satisfactory. Considering the importance of proper documentation of medical records in teaching hospitals as a valid document of educational and medical activities in educational accreditation, the present study was designed and conducted to investigate the effect of training on the quantity and quality of documentation of the patients' records.
Materials and Methods: The present study was an action research study. The status of medical records was first evaluated by residents, interns and externs in 400 randomly selected files. Then, based on an intervention protocol, training programs were held for these individuals and every month defects in the files were reported to the department heads in the form of written feedback. Finally, using SPSS V.22 software, data were analyzed by McNemar's test.
Results Based on the comparison of the studied criteria before and after the intervention, the percentage of history recording, the percentage of on-service note, the percentage of off-service notes, and the percentage of daily progressive note (PN) in all three groups of medical students including externs, interns and residents improved significantly. (P <0.05). In addition, the intervention significantly improved other indicators, including the principles of recording correct diagnosis in the files, recording the time and date and also medication orders, completing the patient education form, obtaining informed consent from the patients in case of need, recording medical consultations correctly and preparation of standardized file summary (P <0.05).
Conclusions: Based on the findings, continuous training and providing regular written feedback can be effective in increasing the quantity and quality of recording necessary items in the patients' medical records by residents, interns and externs.
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| Keywords: Medical records, Teaching hospital, Documentation, Education, Feedback, Action research |
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Full-Text [PDF 373 kb]
(53 Downloads)
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Type of Study: Applicable |
Subject:
Health Management Services
Received: 2021/12/3 | Accepted: 2023/06/26 | Published: 2024/07/10
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