Evaluation of Data Recording at Teaching Hospitals

AUTHORS

Hasan Karbasi 1 , * , M Ziai 2 , M Hosaini 3

1 Faculty Member of Birjand University of Medicine

2 Infectious diseases specialist, Faculty Member and head of community medicine department of Birjand University of Medical Sciences

3 Epidemiology Ms, Faculty Member of Birjand University of Medical Sciences

How to Cite: Karbasi H, Ziai M, Hosaini M. Evaluation of Data Recording at Teaching Hospitals, J Med Edu. 2006 ; 9(2):e105295. doi: 10.22037/jme.v9i2.723.

ARTICLE INFORMATION

Journal of Medical Education: 9 (2); e105295
Published Online: June 01, 2006
Article Type: Research Article
Received: April 01, 2006
Accepted: June 01, 2006
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Abstract

Background and purpose: Medical records of patients have an undeniable role on education, research and evaluation of health care delivery, and also could be used as reliable documents of past in casesof patients’ legal complains. This study was done to evaluate medical data recording at teaching hospital of Birjand University of Medical Sciences in 2004.Methods: In this descriptive-analytic study, 527 patients’ records of patients who had been discharged from general wards of the hospitals after 24 hours of hospitalization were randomly selected. 18 standard titles of records include in each patient’s record were evaluated using checklists. Data were analyzed using frequency distribution tables, independent t-test and Chi-square test.Results: Items on records’ titles were completed in a range of 0-100%. Titles of neonates and nursing care with 96% completeness were the most completed ones~ Titles of recovery, pre-delivery care, medical history, summary, and progress notes with 50% to 74% completeness were categorized as moderately completed titles; and titles of vital signs, pre-operation care and operation report were weak. Records of the infectious diseases ward were the most completed records (68%) and the least completed were from ophthmology ward (35.8%). There were significant differences between the hospitals and between different wards.Conclusion: Results of this study show the need for further education on record writing, taking medical history, and order writing and more importantly the need for a system of continuous monitoringof the records.

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  • © 2006, Journal of Medical Education. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.
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