Assessing the Status of Tools and Methods for Evaluating Physicians' Documentation in the Emergency Department: A Review Study

Documentation of medical records is the first and most important source of patient information collection. On the other hand, the correct registration of medical records is considered as one of the criteria of physicians' scientific skills. Therefore, the purpose of this study was a systemat ic review to examine the status of tools and methods for evaluating the documentation of physicians in the emergency department.

This systematic review was performed in studies related to the evaluation of the documentation status of emergency department physicians. The studies were available from PubMed, Web of Science, Scopus, Irandoc and SID databases by the end of 2020. Titles and abstracts were reviewed independently based on eligibility criteria. After that, the complete texts we re retrieved and independently reviewed by two researchers based on eligibility criteria. A standardized form was used to extract the data including study title, first author name, year s of study, place of study, number of samples, research method, tools, indicators studied and main findings.

A total of 4693 related studies were extracted from the database and finally 40 main articles were included in the study. In 4 cases, the level of documentation was reported to be incomplete and undesirable by examining the registered files; In the other 4 cases, they estimated the amount of documentation as moderate to favorable. In 2 cases, the effect of education and in 2 cases, the effect of feedback and encouragement on documentation were measured. None of the studies provided a comprehensive tool for evaluating physicians' documentation of emergencies; Evaluation patterns were different in each study and were partially reviewed.

A review of research conducted in Iran and the world on documentin g physicians, especially in the emergency department, emphasizes the importance of continuing the process of patients. Consequently, the consequences are the same for all stakeholders in the medical record. In addition, the effect of feedback and encourage ment was more effective than training in improving documentation, so it is suggested that programs be applied for ongoing feedback to documentarians.