Improving the Medical Record Documentation by Quantitative Analysis in a Training Hospital

Completed medical records have an important role in hospital evaluation and one thing that usually reduces evaluation score of medical records department and hospital clinical wards is such defects. Therefore, regarding the importance of this matter, this study was done to study recording status of medical records by physicians in a training hospital. This study was an analytic-descriptive and cross sectional one. The population was inpatients medical record in 2012 and the number of samples was 389 medical records which were chosen by stratified sampling. Finally, after collecting data, they were analyzed by SPSS 13 software both descriptive and inferential statistics and presented in statistical tables. Findings showed that the highest percent is allocated to the presence of progress notes and the lowest percent to recording time of physician first visit. Progress notes was the most incomplete item in wards of NICU, cardiovascular, psychiatric for men, surgery for women, intensive care, emergency, children and psychiatric for women. In wards of CCUII, internal for women, newborns C, and internal for men, lack of physician stamp on summary sheet was the most incomplete item. Progress notes, medical history sheet, and summary sheet were more completed after doing quantitative analysis and using defect eliminating checklist than medical records before November. By attaching defect eliminating form on medical records, we force physicians to complete incomplete records and they understand that completion of these forms will be controlled and these forms have to be completed otherwise records will be referred to them again for completion.