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Quality of patients' files documented by medical students and physicians at Tohid Hospital in Sanandaj
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Asefeh Abbaszadeh1    , Khaled Rahmani2 , Bahar Mosses Gafari 3, Asrin Babahajian4 |
1- School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
2- Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran.
3- , School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran , baharmoassesghafari@gmail.com
4- Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences. MSc, Liver and Digestive Research Center, Sanandaj, Iran |
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Abstract: (1497 Views) |
Background and Aim: Previous studies in Iran have shown that the quality of documentation of medical records by physicians and medical staff is not very satisfactory. The purpose of this study was to investigate the quality of medical records documentation in Tohid teaching hospital, , in Sanandaj, Iran.
Materials and Methods: In this descriptive-analytical study, medical records of 430 patients admitted to various services of Tohid Hospital in Sanandaj during the first six months of 2017 were examined. Variables were collected using a checklist based on the national regulations for the documentation of medical records. Data were analyzed using SPSS V.20 software and Chi-square test.
Results: In the present study we observed registration of the correct diagnosis, in accordance with the principles of diagnosis, in 261 (60.7%) of admission forms and the time of first visit of the physician had been recorded in 282 (66.0%) cases. More than half of the history sheets and most of the initial, daily, and final reports were incomplete. The professors had evaluated 133 (40.7%), 76 (22.0%) and 5 (7.2%) history sheets completed by the residents, interns and externs respectively. About 563 (66.2%) cases of the doctor's prescriptions had been properly recorded in the files. We found correct registration of medical orders by interns and residents and professors in 101 (69.2%) and 186 (87.7%) and 240 (53.7%) cases respectively.
Conclusion: Based on the findings of this study, it is necessary to hold training courses on proper documentation of medical records for physicians and medical students and more precise supervision of professors and physicians on performance of the medical students in all educational hospitals of Kurdistan University of Medical Sciences. |
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| Keywords: Medical record, Health record, Hospital, Documentation |
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Full-Text [PDF 1406 kb]
(552 Downloads)
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Type of Study: Original Research |
Subject:
Health Management Services
Received: 2020/05/26 | Accepted: 2020/10/4 | Published: 2021/09/28
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