Evaluation of Data Recording at Teaching Hospitals

• Main Authors: Hasan Karbasi, M Ziai, M Hosaini
• Format: Article
• Language: English
• Published: Shaheed Beheshti University of Medical Sciences and Health Services 2009-02-01
• Series: Journal of Medical Education
• Subjects: MEDICAL RECORD, TEACHING HOSPITAL, EVALUATION
• Online Access: http://journals.sbmu.ac.ir/jme/article/view/723

<p class="MsoNormal" style="margin: 0in 0in 0pt; direction: ltr; unicode-bidi: embed; text-align: left; mso-layout-grid-align: none;"><span style="font-size: 9.5pt; font-family: Arial;">Background and purpose: </span><span style="font-size: 9.5pt; font-family: Arial;">Medical records of patients have an undeniable role on education, research and evaluation of health care delivery, and also could be used as reliable documents of past in cases</span></p><p class="MsoNormal" style="margin: 0in 0in 0pt; direction: ltr; unicode-bidi: embed; text-align: left; mso-layout-grid-align: none;"><span style="font-size: 9.5pt; font-family: Arial;">of patients’ legal complains. This study was done to evaluate medical data recording at teaching hospital</span><span style="font-size: 9.5pt; font-family: Arial;"> of Birjand University</span><span style="font-size: 9.5pt; font-family: Arial;"> of Medical Sciences in 2004.</span></p><p class="MsoNormal" style="margin: 0in 0in 0pt; direction: ltr; unicode-bidi: embed; text-align: left; mso-layout-grid-align: none;"><span style="font-size: 9.5pt; font-family: Arial;">Methods: </span><span style="font-size: 9.5pt; font-family: Arial;">In this descriptive-analytic study, 527 patients’ records of patients who had been discharged from general wards of the hospitals after 24 hours of hospitalization were randomly selected. 18 standard titles of records include in each patient’s record were evaluated using checklists. Data were analyzed using frequency distribution tables, independent t-test and Chi-square test.</span></p><p class="MsoNormal" style="margin: 0in 0in 0pt; direction: ltr; unicode-bidi: embed; text-align: left; mso-layout-grid-align: none;"><span style="font-size: 9.5pt; font-family: Arial;">Results: </span><span style="font-size: 9.5pt; font-family: Arial;">Items on records’ titles were completed in a range of 0-100%. Titles of neonates and nursing care with 96% completeness were the most completed ones~ Titles of recovery, pre-delivery care, medical history, summary, and progress notes with 50% to 74% completeness were categorized as moderately completed titles; and titles of vital signs, pre-operation care and operation report were weak. Records of the infectious diseases ward were the most completed records (68%) and the least completed were from ophthmology ward (35.8%). There were significant differences between the hospitals and between different wards.</span></p><p class="MsoNormal" style="margin: 0in 0in 0pt; direction: ltr; unicode-bidi: embed; text-align: left; mso-layout-grid-align: none;"><span style="font-size: 9.5pt; font-family: Arial;">Conclusion: </span><span style="font-size: 9.5pt; font-family: Arial;">Results of this study show the need for further education on record writing, taking medical history, and order writing and more importantly the need for a system of continuous monitoring</span></p><p class="MsoNormal" style="margin: 0in 0in 0pt; direction: ltr; unicode-bidi: embed; text-align: left; mso-layout-grid-align: none;"><span style="font-size: 9.5pt; font-family: Arial;">of the records.</span></p><p class="MsoNormal" style="margin: 0in 0in 0pt; direction: ltr; unicode-bidi: embed; text-align: left; mso-layout-grid-align: none;"><span style="font-size: 9.5pt; font-family: Arial;">Keywords: </span><span style="font-size: 9.5pt; font-family: Arial;">M</span><span style="font-size: 6.5pt; font-family: Arial;">EDICAL RECORD</span><span style="font-size: 9.5pt; font-family: Arial;">, </span><span style="font-size: 6.5pt; font-family: Arial;">TEACHING HOSPITAL</span><span style="font-size: 9.5pt; font-family: Arial;">, </span><span style="font-size: 6.5pt; font-family: Arial;">EVALUATION</span></p>