THE QUANTITATIVE STUDY OF THE FACULTY MEMBERS PERFORMANCE IN DOCUMENTATION OF THE MEDICAL RECORDS IN TEACHING HOSPITALS OF MAZANDARAN UNIVERSITY OF MEDICAL SCIENCES.

INTRODUCTION: Documentation of patients' medical records has been always emphasized because medical records are as a means to be applied by patients, all medical staff, quality evaluations of health care, lawsuits, medical education and, etc. Regarding to this, each of the data elements available in the sheets of medical records has their own values. The rate of completion indicates the importance of the medical recorders for faculty member. So in this article the researcher evaluates the completion of medical records in the teaching hospitals of Mazandaran University of Medical Sciences. METHODS AND MATERIALS: This cross- sectional study has been conducted to review the patients' medical cases in five teaching university hospitals. To collect data, a check list was mode based on data element arrangement in four main sheets of admission and discharge, summery, patients' history and clinical examination and progress note sheets. Recorded data were defined as "Yes" with the value 1, not recorded data were defined as "No" with the value 2, and not used data were defined for cases in which the mentioned variable had no use with the value Zero. The overall evaluation of the rate of documentation was considered as %95 -100 equal to "good", 75-94% equal to average and under 75% was considered as "poor". Using the sample volume formula, 281 cases were randomly stratified reviewed. The data were analyzed by the software SPSS version 19 and descriptive statistical scales. RESULTS: The results have shown that the overall documentation rate in all the four sheets was 62% and in a poor level. There was no big difference in the average documentation among the hospital. Among the educational group, the gynecology and infection groups are equal to each other and had the highest record average (68%). Within the all groups, the highest rate has belonged to the documentation of signatures (91%). CONCLUSION: Regarding to the overall assessment that documentation rate was in a poor level, more attempt should be made to achieve a better condition. Even if a data element of the sheets seems meaningless, unnecessary and duplicated, it should not be ignored and skipped. In order to solve such problems, it is suggested that medical records sheets and the elements that seem unnecessary, should be reviewed in relevant committees.

Documentation of Medical Records in Hospitals of Mazandaran University of Medical Sciences in 2014: a Quantitative Study.

INTRODUCTION: Documentation of patient care in medical record formats is always emphasized. These documents are used as a means to go on treating the patients, staff in their own defense, assessment, care, any legal proceedings and medical science education. Therefore, in this study, each of the data elements available in patients' records are important and filling them indicates the importance put by the documenting teams, so it has been dealt with the documentation the patient records in the hospitals of Mazandaran province. METHOD: This cross-sectional study aimed to review medical records in 16 hospitals of Mazandaran University of Medical Sciences (MazUMS). In order to collection data, a check list was prepared based on the data elements including four forms of the admission, summary, patients' medical history and progress note. The data recording was defined as "Yes" with the value of 1, lack of recording was defined as "No" with the value of 2, and "Not applied" with the value of 0 for the cases in which the mentioned variable medical records are not applied. RESULTS: The overall evaluation of the documentation was considered as 95-100% equal to "good", 75-94% equal to "average" and below -75% equal to "poor". Using the stratified random sample volume formula, 381 cases were reviewed. The data were analyzed by the SPSS version 19 and descriptive statistics. RESULTS: The results showed that %62 of registration and all the four forms were in the "poor" category. There was no big difference in average registration among the hospitals. Among the educational groups Gynecology and Infectious were equal and had the highest average of documentation of %68. In the data categories, the highest documentation average belonged to the verification, %91. CONCLUSION: According to the overall assessment in which the rate of documentation was in the category "week", we should make much more efforts to reach better conditions. Even if a data element is recognized meaningless, unnecessary and repetitive by the in charge of documentation, it should not be neglected and skipped. In order to solve the problems of these types, it is suggested to discuss the medical records forms and elements that seem unnecessary in the related committees.

The 10-year Absolute Risk of Cardiovascular (CV) Events in Northern Iran: a Population Based Study.

BACKGROUND: The present study was conducted to estimate 10-year cardiovascular disease events (CVD) risk using three instruments in northern Iran. MATERIAL AND METHODS: Baseline data of 3201 participants 40-79 of a population based cohort which was conducted in Northern Iran were analyzed. Framingham risk score (FRS), World Health Organization (WHO) risk prediction charts and American college of cardiovascular / American heart association (ACC/AHA) tool were applied to assess 10-year CVD events risk. The agreement values between the risk assessment instruments were determined using the kappa statistics. RESULTS: Our study estimated 53.5%of male population aged 40-79 had a 10 -year risk of CVD events≥10% based on ACC/AHA approach, 48.9% based on FRS and 11.8% based on WHO risk charts. A 10 -year risk≥10% was estimated among 20.1% of women using the ACC/AHA approach, 11.9%using FRS and 5.7%using WHO tool. ACC/AHA and Framingham tools had closest agreement in the estimation of 10-year risk≥10% (κ=0.7757) in meanwhile ACC/AHA and WHO approaches displayed highest agreement (κ=0.6123) in women. CONCLUSION: Different estimations of 10-year risk of CVD event were provided by ACC/AHA, FRS and WHO approaches.

Rate of medical errors in affiliated hospitals of mazandaran university of medical sciences.

INTRODUCTION: Health care organizations are highly specialized and complex. Thus we may expect the adverse events will inevitably occur. Building a medical error reporting system to analyze the reported preventable adverse events and learn from their results can help to prevent the repeat of these events. The medical errors which were reported to the Clinical Governance's office of Mazandaran University of Medical Sciences (MazUMS) in years 2011-2012 were analyzed. METHODS AND MATERIALS: This is a descriptive retrospective study in which 18 public hospitals were participated. The instrument of data collection was checklist that was designed by the Ministry of Health of Iran. Variables were type of hospital, unit of hospital, season, severity of event and type of error. The data were analyzed with SPSS software. RESULTS: Of 317966 admissions 182 cases, about 0.06%, medical error reported of which most of the reports (%51.6) were from non- teaching hospitals. Among various units of hospital, the highest frequency of medical error was related to surgical unit (%42.3). The frequency of medical error according to the type of error was also evaluated of which the highest frequency was related to inappropriate and no care (totally 37%) and medication error 28%. We also analyzed the data with respect to the effect of the error on a patient of which the highest frequency was related to minor effect (44.5%). CONCLUSION: The results showed that a wide variety of errors. Encourage and revision of the reporting process will be result to know more data for prevention of them.

Studying the rate and causes of discharge against medical advice in hospitals affiliated to mazandaran university of medical sciences.

INTRODUCTION: Discharge against medical advice from the hospital is an important issue from point of view of treatment management, health costs as well as the side effects of treatment stop on patients and their accompanying. Therefore, health managers and planners should consider the predisposing factors that change patient's mind in this regard. Since, there has been no study to carefully assess the rate and causes of self-discharge in this province, so this study is aimed to fill this gap. METHODS AND MATERIALS: This descriptive and cross-sectional study was carried out in 6 months period, from 23 July 2010 till 20 January 2011 in all public hospitals of Mazandaran province. A form was set out for data collection and those patients willing to self-discharge were asked to participate in the study. Patients' demographic information was filled using their medical record and by the help of department personnel. Furthermore, the form was completed by parents for patients over 18 year-old or by the help of first-rank relative for those having psychiatric disorders or anybody who wasn't able to complete the form. In order to identify the causes of self-discharge, 18 variables were determined which were categorized in three general items and five main groups. Data were entered into the SPSS15 and were analyzed using descriptive statistics indices. RESULTS: According to the results, 94441 were discharged from the university hospitals which 7967 patients (8.4 %) of them were self-discharged during the 6 month study period. Regarding admission type, 269 (3.3 %), (54.5 %) were admitted into the hospital by pre-determined appointment and as usual patients, respectively, and the rest were admitted by emergency department. Also, 31.4%(2504) were hospitalized in surgery ward, 63% (5026) in medical ward, 4.6% (374) in intensive care unit (ICU) and the rest were hospitalized in the psychiatric ward. The most important reasons for self-discharge were related to: 1-factors affecting patient illness (54.3%), 2-environmental issues as well as patients' accompanying (37.6%) and 3-managerial and medical reasons(7.9%), respectively. CONCLUSION: Our study showed the same results for Discharge against medical advice rate as the others. From the view point of treatment management, its causes should be considered and practices should be done to improve the conditions. Meanwhile, the current self-discharge form doesn't reflect the causes of the problem and it should be revised.

Clinical findings leading to the diagnosis of sepsis in neonates hospitalized in Imam Khomeini and Bu Ali hospitals, Sari, Iran: 2011-2012.

BACKGROUND: One of the important diseases in neonatal period is sepsis. Clinical sign and symptoms in addition to lab tests are the most important way to accurate diagnosis and prevention of mortality. This study was conducted with the aim of determining the most clinical sign and symptoms which leading to diagnosis of sepsis. MATERIALS & METHODS: This is a descriptive cross-sectional study. The medical records of patients hospitalized in hospitals of Mazandaran University of Medical Sciences during 2011-2012 were reviewed. Variables were age, sex, birth and admission weight, clinical sign and symptoms, methods of delivery, admission and discharge condition, discharge status, the time elapsed between showing the symptom and admission to hospital, gestational age and the result of cultures. The data were recorded in a checklist and analyzed with SPSS and descriptive statistics. RESULTS: finding showed that 120 patients discharged during period of study with diagnosis of sepsis. Discharged status of 27 (%22/5) were expired. Median age was 1 day with 8 hours SD, length of stay were 12±1 days, gestational age was34±3 weeks and median birth weight was 2477±977 grams. The median time elapsed between showing the symptom and admission to hospital was 38±31 hours. Blood culture in 10 (%8/3) and urine culture in 8 (%7/6) patients were positive. None of patients have positive lumbar puncture culture. The frequent sign and symptpms in patients were respiratory distress, poor feeding and lethargy. CONCLUSION: Early diagnosis of neonatal sepsis is not possible only by specific laboratory exams. Clinical sign and symptoms can help us to prediction and diagnosis of neonatal sepsis. Results of this research revealed that it is not clear which one of manifestations was started first or the second because of medical history sheets don't show this process.

Adverse events in affiliated hospitals of mazandaran university of medical sciences.

Due to the complexity of the hospital environment, its structure faces with multiple hazards. The risks whether by providing the care and whether by hospital environment endanger patients, relatives and care providers. Therefore, a more accurate reporting and analysis of the report by focusing on access to preventative methods is essential. In this study, hospitals' adverse event that has sent by affiliated hospitals of Mazandaran University of Medical Sciences to deputy for treatment has studied.

Survey of keyword adjustment of published articles medical subject headings in journal of mazandaran university of medical sciences (2009-2010).

CONFLICT OF INTEREST: NONE DECLARED. INTRODUCTION: Keywords are the most important tools for Information retrieval. They are usually used for retrieval of articles based on contents of information reserved from printed and electronic resources. Retrieval of appropriate keywords from Medical Subject Headings (MeSH) can impact with exact, correctness and short time on information retrieval. Regarding the above mentioned matters, this study was done to compare the Latin keywords was in the articles published in the Journal of Mazandaran University of Medical Sciences. METHOD: This is a descriptive study. The data were extracted from the key words of Englsih abstracts of articles published in the years 2009-2010 in the Journal of Mazandaran University of Medical Sciences by census method. Checklist of data collection is designed, based on research objectives and literature review which has face validity. Compliance rate in this study was to determine if the keywords cited in this article as a full subject of the main subject headings in a MeSH (Bold and the selected word) is a perfect adjustment. If keywords were cited in the article but the main heading is not discussed in the following main topics to be discussed with reference to See and See related it has considered has partial adjustment. RESULTS: Out of 148 articles published in 12 issues in proposed time of studying, 72 research papers were analyzed. The average numbers of authors in each article were 4 ± 1. Results showed that most of specialty papers 42 (58. 4%), belonging to the (Department of Clinical Sciences) School of Medicine, 11 (15.3%) Basic Science, 6(8.4%) Pharmacy, Nursing and Midwifery 5(6.9%), 4(5.5%) Health, paramedical Sciences 3(4.2%), and non medical article 1(1.3%) school of medicine. In general, results showed that 80 (30%) of key words have been used to complete the adjustment. Also, only 1(1.4%) had complete adjustment with all the MeSH key words and in 8 articles(11.4%) key words of had no adjustment with MeSH. CONCLUSION: The results showed that only 17 articles could be retrieved if the search words are selected from the MeSH. In this case the expected 100% of published articles titles at this university the validity of exchange of research projects which is something noteworthy. The lack of correlation between number of authors and matching of Keywords with MeSH, may mean all of the papers' authors did not take part in writing and it is understanding that only one author wrote the paper.

Prevalence of resistance to antibiotics according to International Classification of Diseases (ICD-10) in Boo Ali Sina Hospital of Sari, 2011-2012.

INTRODUCTION: One of the issues in health care delivery system is resistance to antibiotics. Many researches were done to show the causes and antibiotics which was resistance. In most researches the methods of classifying and reporting this resistance were made by researcher, so in this research we examined the International Classification of Diseases 10 the edition (ICD-10). METHODS AND MATERIALS: This is a descriptive cross section study; data was collected from laboratory of Boo Ali Sina hospital, during 2011-2012. The check list was designed according the aim of study. Variables were age, bacterial agent, specimen, and antibiotics. The bacteria and resistance were classified with ICD-10. The data were analyzed with SPSS (16) soft ware and the descriptive statistics. RESULTS: Results showed that of the 10198 request for culture and antibiogram, there were 1020(10%) resistance. The specimen were 648 (63.5%) urine, blood 127(12.5%), other secretion 125 (12/3%), sputum 102 (10%), lumbar puncture 8 (0/8%), stool 6 (6/0%) and bone marrow 4 (0.4%). The E coli was the most 413 (40.5%) resistance cause to antibiotics which was coded with B96.2 and the most resistance was to multiple antibiotics 885(86.8%) with the U88 code. CONCLUSION: The results showed that by using the ICD-10 codes, the study of multiple causes and resistance is possible. The routine usage of coding of the ICD-10 would result to an up to date bank of resistance to antibiotics in every hospitals and useful for physicians, other health care, and health administrations.