[Quantitative investigation of inpatients' medical records in training and social security hospitals in Mashhad]

ABSTRACT

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