Quantitative Investigation of Inpatients’ Medical Records in Training and Social Security Hospitals in Mashhad

Document Type : Original Article

Authors

1 Assistant professor, Department of Medical records and Health Information Technology, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran

2 Associate professor, Department of Health& management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran

3 Ph.D. candidate in Medical Informatics, Department of Medical Informatics, School of Medicine, & Faculty Member of department of Medical records and Health Information Technology, School of Paramedical, Mashhad University of Medical Sciences, Mashhad, Iran

Abstract

Purpose:
Medical records should be documented according to the patients’ health care to act as a lifetime documents. These documents should meet the primary and legal requirements related to patients’ care. The aim of this research is Quantitative evaluation of inpatients’ medical records in training and Social Security hospitals in Mashhad.
Methods:
This research is a descriptive-cross sectional survey. 550 of medical records were selected from each hospital with regard to the number of total medical records per year. After confirming the validity and reliability of the checklist, data gathering was performed and analyzed with SPSS statistical software.
Results:
Findings of the present study showed that the admission and discharge summary forms were not existed in one of the selected medical records (%0.01). The most deficiency was related to the vital signs form (%34.5). The most common deficiency among clinical data elements of admission and discharge summery forms was related to the discharge program (%89.9) in addition to the results of lab tests and radiographies (%88.9). In most cases, there was a significant difference between the completeness of data elements of medical records in training hospitals and social security hospitals.
Conclusion:
Results of the present study showed that the documentation process of medical records is performed incomplete by care providers which lead to data loosing. Therefore, providing enough educations about complete and correct documentation of medical records for care providers is advisable. In addition, it is preferable that quantitative review of medical records be performed by staffs of the medical record departments immediately after the care/event, which is called the concurrent review. 

Keywords

Main Subjects


1. Francis CM, Mario CS. Hospital Administration. 3rd Ed. New Delhi, Japee Brothers 2000: 40-185.
2. Vatankhah S, A Survey on Social Security Managers Attitude's in Related to Health Insurance Problems. Iran University of Medical Sciences, Faculty of Medical Informatics and Management 1995. [Persian].
3. Moghadasi H. Information Quality in Health Care. Tehran; Vajehpardaz; 2005. [Persian]
4. Lynch J. Health record in court. UK, Radcliffe publishing Ltd 2009: 2.
5. Roach WH, Hoban RG, Broccolo BM, Roth AB, Blanchard TP.  Medical records and the law. Jones and Bartlett, Forth Edition, 2006.
6. Mashoofi M, Emami F, Rostami Kh, Mardi A. Evaluation of Information Documentation in Hospital of Ardebil University of Medical Sciences. Scientific journal of Ardebil University of Medical Sciences in Iran 2004; 3(11): 20-25. [Persian].
7. DiSantostefano J. Mastering the Basics of Medical Documentation.    The     Journal     for     Nurse Practitioners 2007; 3(3): 190-1.
8. Cox JL, Zitner D, Courtney KD, MacDonald DL, Paterson G, Cochrane B, et al. Undocumented Patient Information: An Impediment to Quality of Care. The American Journal of Medicine 2003; 114(3): 211-6.
9. Dana c. Mcway, JD. Todays Healtrh information management; an integrated approach. Thomson Delmar Learning, 2008.
10. Farzandipoor M, Rabiei R. Principles of Medical Information Documentation. Kashan: Morsal; 2005. [Persian]
11. Ahmadzadeh F, Study of Medical Records Completeness in General Hospitals of Shiraz University of Medical Sciences. Health Information Management 2004; 1(1): 33. [Persian]  
12.Tavakoli N, Saghaeyannejad S, Rezayatmand MR, moshaveri F, Ghaderi I. Deductions Applied by Khadamat-e-Darmani Insurance Company on Patients Bills at Teaching Hospitals Affiliated to Isfahan University of Medical Sciences. Health Information Management 2007; 3(2): 53-61. [Persian].
13. Hajavi A. Medical Records 1, 2. Tehran: Ministry of Health in Iran; 1997. [Persian]
14. Rangraz jedi F, Farzandipoor M, Moosavi Gh. A Survey on Rate of Medical Record Documentation of Urgent Patient in Kashan Hospitals. Faze Scientific journal 2004; 3(21): 68-73. [Persian]
15. Ariayee M. A Survey on Content of Medical Records in General Hospitals of Shiraz University of Medical Sciences. Iran University of Medical Sciences, Faculty of Medical Informatics and Management; 1998. [Persian]
16. Vafaee A, Shidfar MR. Evaluation of a nursing intervention project to promote patient medication education. Nezamesalamat Scientific journal 2009; 1(1):31-41. [Persian]
17. Moghadasi H. Principles of Medical Record Documentation. [Educational Pamphlet]. Workshop of Diagnostic Documentation Based on ICD. Vice chancellor of Research of Ministry of Health in Iran, 2000.
18. Sobhani A, Shojaee ehrani H, Vaghari S.A. Assessment of Record Summaries and History Taking in Internal Ward. Scientific journal of Ghazvin University of Medical Sciences in Iran 1999; 4(12):52-58. [Persian].
19. Moghadasi H. Health Data Processing. Tehran: Vajehpardaz; 2008. [Persian]
20. Mehrabi N. Comparison of Physicians and Nurses Performance in Medical Record Documentation for Inpatient in Iran University of Medical Sciences. Iran University of Medical Sciences, Faculty of Medical Informatics and Management; 1998. [Persian]
21. Asadi F. Evaluation of Medical Records Quality. Scientific journal of Health Management of Iran University of Medical Sciences 2000; 4(50): 20-25. [Persian]
22. Asadi F. A Survey on Rate of Information Documentation for Urgent Patients. Scientific Professional Research journal of Hospital 1997; 6(31). [Persian].
23. Moradi Gh. A Survey on Medical Records Usage in Clinical Research in Hospital of Mashhad University of Medical Sciences. Iran University of Medical Sciences, Faculty of Medical Informatics and Management; 1994. [Persian]