Assessment of record summaries and history taking in internal ward

Background: Writing down records of patients and record summaries are very important for legal, medical and economical purposes. Objective: To determine the completeness of record summaries and records written down by interns of internal medical department. Methods: In a survey study, 1824 records of patients, hospitalized in the medical ward of Razi hospital in Rasht, were studied in 1397. Data collection was carried out on the basis of criteria in the book of clinical examinations and the completeness rate was determined by an ordinal scale. Findings: The study revealed the poor quality of the variables related to the nasal examination and the genital organs of the variable (100%). There was high quality of the variables relating to the lung and heart examination (Poor quality 2.52% and 6.63% respectively). Conclusion: Due to the undesirable results on summary records, a comprehensive study in other departments and also an educational plan for the medical staff is recommended.