What they fill in today, may not be useful tomorrow: Lessons learned from studying Medical Records at the Women hospital in Tabriz, Iran

<p>Abstract</p> <p>Background</p> <p>The medical record is used to document patient's medical history, illnesses and treatment procedures. The information inside is useful when all needed information is documented properly. Medical care providers in Iran have complained of low quality of Medical Records. This study was designed to evaluate the quality of the Medical Records at the university hospital in Tabriz, Iran.</p> <p>Methods</p> <p>In order to get a background of the quality of documentation, 300 Medical Records were randomly selected among all hospitalized patient during September 23, 2003 and September 22, 2004. Documentation of all records was evaluated using checklists. Then, in order to combine objective data with subjective, 10 physicians and 10 nurses who were involved in documentation of Medical Records were randomly selected and interviewed using two semi structured guidelines.</p> <p>Results</p> <p>Almost all 300 Medical Records had problems in terms of quality of documentation. There was no record in which all information was documented correctly and compatible with the official format in Medical Records provided by Ministry of Health and Medical Education. Interviewees believed that poor handwriting, missing of sheets and imperfect documentation are major problems of the Paper-based Medical Records, and the main reason was believed to be high workload of both physicians and nurses.</p> <p>Conclusion</p> <p>The Medical Records are expected to be complete and accurate. Our study has unveiled that the Medical Records are not documented properly in the university hospital where the Medical Records are also used for educational purposes. Such incomplete Medical Records are not reliable resources for medical care too. Some influencing factors external to the structure of the Medical Records (i.e. human factors and work conditions) are involved.</p

A Study on Knowledge and Considering of Consents Legal Aspects in Teaching Hospitals of Shahid Beheshti University of Medical Sciences 2008

Abstract Introduction: Obtaining the consent for medical care is a legal force; consent forms are written behind the admission forms. Admission personal should obtain suitable warrant from patients or their families for doing procedures. So they should be aware of the consequences of their actions. This study was aimed to determine relationship between the knowledge and considering of legal aspects of consents in the teaching hospitals of Shahid Beheshti University of medical sciences. Methods: This is a descriptive-cross-sectional study carried out in 2008. Subjects include 11person and 43 people of admission personal in the teaching hospital of Shahid Beheshti University of Medical Sciences. Data were collected by questionnaire and checklist; and analyzed by SPSS, and Pierson. Results: Our findings showed that the rate of knowledge of administrators of medical record&apos;s departments from legal aspects of consents was %72/7; and the rate of consideration was %68/6, and the rate of relationship was 0/683. The rate of knowledge of admission personal was %66/3, and the rate of consideration of them were %62/9 and the rate of relationship between them was 0/558; so there is a strong positive relationship between them. Conclusion: There is relationship between the knowledge and consideration of legal aspects about consents in administrators of medical record&apos;s departments and admission personal (P&lt;0.011) an

Medical records standards in selected countries and Iran: a comparative study.

Studies conducted in Iran showed that the absence of specific and applied standards relating to medical records, and the absence of a custodian organization, resulted in an incompatibility of medical records with standards and a deviation in the path of the activities of medical records departments from their main goals. Today's medical record professionals identified the development of a mechanism for establishing medical records standards as a reform priority. So, conducting a comparative study of related medical records standards in developed countries with Iran, is important in order to facilitate a nationwide standardization movement in Iran's medical record departments