Evaluation of Data Recording at Teaching Hospitals

Hasan Karbasi; M Ziai; M Hosaini

doi:10.22037/jme.v9i2.723

Journal of Medical Education for Future Demands

Former Title: Journal of Medical Education | The Official Journal of School of Medical Education and Learning Technologies

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https://doi.org/10.22037/jme.v9i2.723

Evaluation of Data Recording at Teaching Hospitals

Author(s):

Hasan Karbasi^1,*,

M Ziai²,

M Hosaini³

1Faculty Member of Birjand University of Medicine

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

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

Journal of Medical Education for Future Demands:Vol. 9, issue 2; e105295

Published online:Jun 01, 2006

Article type:Research Article

Received:Apr 01, 2006

Accepted:Jun 01, 2006

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

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.

Keywords

Medical Records

Teaching Hospital

Evaluation

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Author(s):

Hasan Karbasi:[PubMed][Scholar]
M Ziai:[PubMed][Scholar]
M Hosaini:[PubMed][Scholar]