RESUMO
Background: the role of Medical Information system in Health Centers is so important because this system improves the quality of health care settings. Complete recording of patient's management process will show the accuracy of health care setting medical record system. The main goal of this research is the study of Medical Records system Role in Imam Reza Hospital in 2005 - 06
Materials and Methods: This research is a cross sectional - descriptive one. The sampling population includes Admission, Statistics, Coding, Archives and the patients discharge information part in 2006. Sampling of patients' records was done on the basis of systematic random and checklist was used for collecting data, and analyzed with Excel program
Results: Findings of the research show that all investigated Medical Records Departments have relatively good facilities and they had a good working performance. Coding Unit had the best working performance with Good Level and the weakest level belonged to Admission unit. Facilities of the archive unit was the best Level and the weakest level belonged to Admission unit. Nursing Report had the best Level and the weakest level belonged to Patient's medical progress sheet
Conclusion: It can be concluded that Admission unit has the weakest performance with the least facilities. On the other hand, Coding Department has good performance. Patient's data elements were recorded well by nurses in the main forms, and physicians had a least result of in Patient's medical progress sheet. Vital Signs Control Forms were not documented in most occasions except in some cases. Although admission unit in Imam Reza hospital is controlled by nursing authority, if we want to obey the standards and increasing the quality of health recording system, admission unit must be managed by medical record department