[Rate of consent validity in patients from teaching hospitals in Sari]

Quality of data in patient record is not a new issue. Data quality requires many details, which in this article we analyzed for validity of consent. This is a patients right and hospitals must pay attention to it, prior to providing their services. This is a descriptive chart review research. Variables are age, sex, type of admission, degree of-understanding, general condition at time of admission, and the person who signed the consent for chart, using medical information, validity of consent and education of admission clerk. This was a pilot study within each hospital, according to the number of clerks, thus, 30 records were reviewed. Validity of consent confirmed with comparison of consents with the standards. Data was analyzed with SPSS software, X2 statistics were used for determining the relation between variables and P<0/05 was significant. Results showed that of the 540 records which were reviewed, 266 [49/4%] of the patients were males and remaining were females. Range of age was from 1 day to 89 years of age. Type of admission for 258 [47/8%] was emergency and the others were admitted electively. Degree of conscious for 477[88/5%] were awake and 442[82%] were in good general condition. The 403 [74/6%] consent for care were not valid and 125[23/1%] of the consent for using data of medical records in research was also not valid. The results of this research indicated that most consent is not reliable. Every effort must be made to ensure the development of consent validity

[Designing a form for request to transfusion of blood and its products]

One of the methods for knowledge transferring is documentation of procedures done in a documentary process, whether in a paper or electronic format. For creation reporting process of monitoring the rate of blood request, uses, and reactions, also unused blood after cross matching test, a form with the ability to drive statistical reports, covering deficiencies of current form, was needed. So according to needed reports, protecting documentary in a medico legal aspect, a form was designed regarding scientific rules, current Iranian format, and WHO regulations. Of course every topic has capacity for discussion and designer will appreciate all criticism ideas

[Rate of hospitalized patient following complication of surgery, Imam hospital, Sari]

Complication of surgery is one of the causes in further reference of inpatients to the hospital. Survey on complications is important resource in evaluation of rendered care to patient. This is a cross sectional retrospective study. Medical records of patient who discharged with complication of surgery during 2000- 2007 from Imam Hospital were reviewed. A check list was designed for data collection according aims of research and review of literature. According to the ICD-10, complication classified in 3 types. Type on is certain complications related to surgical and other procedural e.g surgical wound infection, mechanical complication of implanted device. Type 2 conditions that occur either as a consequence of specific procedure or technique or as a result of the removal of an organ e.g post mastectomy lymphoedema and the final type is conditions that arises in the post procedural period e.g pneumonia and pulmonary embolism. The data were analyzed with SPSS soft ware and descriptive statistics. The results shown that during the years 2000-2007, the 72281 surgery was done. And the medical records of 409 patients were reviewed. The primary surgery of 292 the patients were done in Imam and the rest of them were admitted in this hospital only for complication of previous surgery which was done in other hospitals. According the ICD-10 classification and during five times hospitalization, 407[88%] of the patients have the type one complication, 53[11/6%] of them the second one. The third one was not occurred in any patients. The results of this study have shown that, the rate of hospitalized patient following complication of surgery was 0/65%. Of course with the preventive precaution and finding the effective factors especially in evaluation process can decrease this rate

[Frequency of blood transfusion and its products in Emam hospital of Sari]

Blood is a life saving product and has no equivalent. Limitation time for storing and cost of typing and cross matched in respect of lab equipment and personnel, may lead to importance of proper request and use of them. In a cross sectional descriptive study, 500 patients with elective surgery were participated. Variable and data collection were done with check list. Data analyzed with SPSS soft ware. The standard ratio of cross matched per transfused was less than 1/5 pack. Results shown that of 500 patients, the blood transfused only for 80[16%] of them. The mean of hemoglobin for patients who have transfused were 12/4. The mean of hemorrhage for patients who have transfused were 822 milliliters and for the rest were 424. The whole products which used were, 325 packs and 15 units were platelet and the rest were whole blood and packed cell. In this study the ratio of cross matched blood with transfused was 4 packs higher than standard. Because of costs for storing, reservation, transport to hospitals, and costs of cross matched in respect of lab costs and staffs, the request of blood must be by real indication and exact needs

[Rate of general health, job stress and factors in medical records workers]

Hospital staff, because of their responsibility for keep health and treatment of patients, may be affected by many stressful factors. In this study, rate of general health, stress level, and stressful factors in medical records staff working in Mazandaran hospitals was surveyed. In this descriptive [cross sectional] research, all medical record staff were participated [no sampling]. General health questionnaire [GHQ], Osipow questionnaire [for rate of stress], and a researcher made questionnaire [for find out the stress factors] were used. Data was analyzed with SPSS software. The staff working in private hospitals had a better general heath condition. Medical records administrators had more stress. The rate of stress in medical records staff [with academic degree] and in staff with no academic degree was in the same level; but general health level in staff with academic degree was higher. k2 test showed that there was not any significant relation between rate of general health [P = 0.06], stress [P = 0.21] and course of education. The general health condition in all staff was in acceptable rate. Also, the stress level was in natural rate. Attention to medical records workers because of relationship with patients and duration of the time which they must work, for removing stressful factors is suggested