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 boundaries of providing health services for patients is so much expanded that it is not, at least an economical cost-effective activity in the framework of the health insurances. In many countries the complementary health insurances have been used to provide these services. The aim of this study is to comparison between complementary health assurance structure and content in selected countries; and presenting a paradigm for Iran. The present study is an applied descriptive study, has been done comparatively between 1383-1384 [2003-2004]. Parameters such as management and organizations, population coverage, the criteria to choose the insurance fees, services and their reimbursement payments methods, limitations and the obligations of the services; supervision and evaluations; in countries such as USA, Germany, Slovakia, Britain, Belgium, France, Finland, Philippine, Netherlands, and Iran has been chosen based on the Gordon Model. The chosen methods are based on Delphi techniques and by using the statistical tests were analyzed. Our study results showed that the main reason of choosing the complementary insurance is the insufficient coverage of the public health insurance [89%]. The High Council for Health selected as responsible authority for approving complementary health insurances [78%], also because of decentralized organizational structure of the delivery systems for the complementary health insurances fees fixed based on actual services prices, given the competitive principle [78%]. Using insurances in terms of governmental and private complementary health insurance and creating the competition among them, could have an important role on improvement the health insurance quality, raising the level of customers' satisfactions, and finally improve the public health