RESUMO
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. 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. 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. 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
RESUMO
The information gathered in hospitals for clinical services is massive and management of this dispersed information is very complicated, however, necessary for medical centers. Considering the computer capabilities, clinical information systems are very useful and efficient in achieving the management goals in medical centers. This study was conducted for evaluating different applications of clinical information systems and staff awareness of Medical Records Department. This study was conducted in two-steps: In the first step, the available resources during 2000-2011 were studied. In the second step, awareness of clinical information systems among Medical Record Department's staff of Tehran University of Medical Sciences hospitals has been evaluated. The validity of the questions raised in questionnaire was confirmed by the expert panel and its reliability was determined to be 80% by test-retest coefficient. The collected data was analyzed using MS Excel 2007 software. The clinical information system consists of different parts and a variety of applications including: clinical documentation, making decision, management of medicine, radiology, laboratory, etc. There are barriers such as financial, behavioral and technical issues to employ these systems. The results obtained from the second part showed that the average of staff awareness of clinical information systems was 49%. Considering the numerous benefits of clinical information systems, using it for supplying information on clinical centers is an inevitable necessity. Selecting a proper system, training users, and paying attention to the factors affecting their implementation in hospitals play a key role in its clinical effectiveness and widespread use of clinical information systems