جستجوی مقالات مرتبط با کلیدواژه « مستندسازی » در نشریات گروه « پزشکی »

Introduction:

Accurate documentation of medical records is one of the important issues during the process of diagnosis and treatment of the disease. It is very important in terms of treatment, legal, educational, financial and research. This study aimed to determine awareness of medical students about principles of medical records documentation.

This descriptive-analytical and cross-sectional study was conducted in 2022-2023 at Zahedan university of medical sciences. The research population included medical students in the preclinical, clinical, and residency levels. The sample size was 260 medical students and the sampling method was quota sampling. The data collection tool was a researcher-made questionnaire. The validity and reliability of questionnaire were confirmed. Descriptive statistics (frequency, percentage, mean, and standard deviation) and analytical tests (T-test and One-way ANOVA) were used to analysis the research data.

The average awareness score obtained by the research community was 64.92±14.02 out of 74. The highest and lowest average scores were respectively related to the principles about the time frame of completing the information and the general principles of documenting the medical record. The test of the relationship between the variables of the research showed that only the relationship between the two variables of awareness level and educational level of students was significant.

In this study, the level of students' awareness about the principles of documenting medical records was optimal. But by comparing the different results of this research with previous similar studies, it can be said that teaching the principles of documentation over time has had a positive effect on improving the level of students' awareness.

Continuous evaluation of medical record documentation is needed for a quality patient care. This study aims to evaluate the status of nursing documentation before and after providing feedback to nurses in the emergency department (ED) of a hospital in Mashhad, Iran.

This quasi-experimental study was conducted in the ED of Imam Reza Hospital in Mashhad in 2022. First, the ED nursing documentation assessment tool was developed based on the literature review and its psychometric properties were evaluated. Then, 150 medical records were randomly selected from the ED and examined by this tool. The results of assessment along with the guideline for correct documentation were given to the nurses as feedback in a video format. One month after, 150 medical records were examined again and the results compared. Data were analyzed in SPSS software, version 22 using the independent t-test, chi-square test, and Fisher’s exact test.

Of 22 indicators in the initial draft of designed tool, 18 obtained acceptable CVR (>0.56) and CVI (>0.79). Cronbach’s α coefficient for the designed tool was obtained 0.85. The mean score of nursing documentation before giving feedback was 27.9±2.1 (out of 36) which increased significantly to 29.1±1.6 after giving feedback (P<0.001). The highest percentage of incomplete documentation was related to the triage form and compliance with the principles of correction or addition.

The status of nursing documentation in the ED of study hospital can be improved by the feedback method. It is recommended to regularly evaluate the nursing documentation status in this department and provide feedback to the nurses.

Clinical coding is a complex and error-prone process. Correct clinical coding requires high-quality documentation of medical records. This study aimed to identify the quality of medical records documentation and the accuracy of coding with ICD-10 compared to ICD-11.

This cross-sectional descriptive study was conducted in 2022. The samples were chosen from 11638 medical records of patients admitted at the Shahid Mohammadi teaching hospital with the diagnosis of injury, poisoning, and certain other consequences of external causes. Using Cochran's formula, 500 medical records were evaluated. The research was conducted in two stages to check the accuracy of coding and the defects in the documentation of medical records for coding. The research data collection tools were separate checklists for each stage. Data were analyzed using descriptive statistics in SPSS software.

The number of codes allocated to the studied medical records was 1673 and 1468 codes based on ICD-10 and ICD-11 classification systems, respectively. The majority of records (98%) had at least one type of major or minor error, 23% had only major errors, 46% had only minor errors, and 31% had both types of ICD-10 coding errors. Moreover, 81% and 26% of the medical records contained adequate information to fully or relatively fully describe the codes using ICD-10 and ICD-11 classification systems, respectively.

Compared to ICD-10, there were more defects in the documentation of medical records for coding with ICD-11. Development written documentation guidelines by ICD-11, using templates and reminders, and providing feedback to healthcare providers. Using automated coding support tools, coding audits, and continuous training of coders are essential for coding quality improvement.

The payment system based on diagnosis-related groups was created to control the costs of health care services, increase efficiency in inpatient care, and improve transparency in hospital activities. The success of this system depends on complete and accurate documentation of medical records and correct coding of diagnoses and procedures. This research aimed to determine the problems of documenting medical records to implement a payment system based on DRGs.

This research was a qualitative study that was conducted using the semi-structured interview method in 2022. The research population included experts in health information management and health economics at Urmia University of Medical Sciences, who were selected purposefully. Data analysis was done through content analysis using ATLAS.ti software.

From the point of view of the interviewees, the most important problems of documenting medical records in the implementation of DRGs, included the lack of clinical documentation guidelines, the lack of necessary information elements, the lack of accurate evaluation of the quality of documentation, and coding, the lack of continuous training courses, the incompleteness of documentation, and the lack of sufficient interaction between doctors and coders were in the hospital.

The results of this research showed that some essential variables for implementing the DRGs system are not defined separately and clearly in the medical records and the hospital information system, and the quality of the documentation and coding is not accurate and complete. Therefore, it seems necessary to consider separate information elements for the main diagnosis, the main action, and the comorbidity and complications in the standard medical record forms.

Discharge summaries (DSs) are among the most important tools for transferring information from hospital physicians to other physicians and play an important role in the continuity of care. Low quality and lack of information are the main problems of DSs, and evaluation of their quality from the physicians' perspective in Iran has rarely been done. This study aimed to evaluate the DSs' quality of content and completeness.

This descriptive cross-sectional study was performed on the DSs of Shafa Hospital in Kerman. A valid and reliable researcher-made questionnaire (α=0.97) was used. This questionnaire had three sections, including questions related to demographic information, evaluation of the quality of DSs (8 questions), and the degree of completeness of the DSs (8 questions).

Out of 110 physicians, 98 (89%) filled out questionnaires. Completeness, awareness, continuity of care, legibility, relevancy, length, consistency, organization, and physicians’ satisfaction were below the average (50%) throughout the hospital. The highest level of physicians' satisfaction with the quality of the content (79.27%) and completeness (77.73%) was attributed to electronic discharge summaries of the neurology department. Organization, legibility, and consistency, respectively, were identified as the best predictors of physicians' satisfaction with the quality of the DSs’ content.

Policymakers should increase the quality of DSs by creating instructions, holding documentation training courses, increasing the supervision of senior physicians on interns and residents, and finally developing electronic automated DSs.

Medical record documentation by physicians in the emergency department is very important because it determines the required services of patients in the next step. This study aimed to design and implement appropriate tools for the rapid assessment of physicians' documentation in the emergency department.

The present study was a cross-sectional study. First, a comprehensive review of resources was done in Google Scholar, PubMed, Web of Science, Scopus, Iran doc, and SID until 2021. Physician documentation indicators were provided to health information management specialists, emergency medicine specialists, forensic specialists, and the head of the HIM department in hospitals. Intra-class correlation coefficient (ICC) was used to evaluate face and content validity for instrument reliability. Then, the proposed tool randomly selected and reviewed 230 medical records of Imam Reza (AS) Hospital in Mashhad. Data were analyzed using SPSS 21 software.

First, a tool with 26 indicators was developed. Intra-class correlation coefficient (ICC) was obtained from the test of 30 medical records 0.980, which was acceptable. Seventeen indicators had scores higher than 0.79, 0.714, and 3.55 and CVR and face validity, including signature, date and time, diagnoses and procedures, correction of errors. The assessment results of 230 medical records showed a relatively good state of documentation of emergency physicians.

The proposed tool allows the rapid assessments of the key index in the documentation of physicians in the emergency department and has high validity and reliability, so it is recommended to be used in the emergency department.

Despite the implementation of hospital information system, in some countries, medical records are still documented in traditional ways. Incomplete documentation in medical records can lead to inappropriate medical decisions and higher costs. The purpose of this study was to investigate the deficiencies of the main forms in medical records by the role of documentarians.

This cross-sectional study was conducted in Shafa hospital in Kerman in 2019-2020. The medical records of this hospital were randomly selected. The completion or non-completion of data elements in the main forms of medical records was examined using a valid and reliable checklist. The collected data were analyzed using descriptive statistics in SPSS 24.

The result of this study demonstrated that 34.70% of the selected records for each patient were incomplete. In most forms, ward secretaries did not complete the relevant data elelments. In other forms, nurses and physicians did not complete more than half of the data elelments. The highest number of deficiencies were observed in the electrocardiogram attachment sheets, emergency records, and radiographic request forms, respectively.

Some data elements such as demographic information, initial diagnosis, final diagnosis, and signatures were not completed by ward secretaries, physicians, and nurses. Non-completion of data elements may lead to problems in providing services to patients. Evaluating the extent of medical record deficiencies based on the role of documentarians can be effective in modifying the forms and developing future training programs.

Emergency medical services (EMS) are among the major concerns in health care. Documentation of patient care in medical records format is of great importance since they are used in further treatments, assessment of care, medical-legal reports, and medical educations.  

This descriptive cross-sectional research was performed by studying the emergency records available in five educational centers affiliated with Mazandaran University of Medical Sciences, 2018. A checklist was compiled based on a guideline for EMS records recommended by Iran Ministry of Health and Medical Education. Values 1 and 2 were considered for data recorded and not recorded, respectively. In cases of no valuable data a value of 0 was considered. Four hundred fifty files were selected using the sample size formula. Data were analyzed in SPSS V21 applying descriptive statistics.

The overall rate of emergency medical records was 62% and was considered poor. Among the centers studied, Qaemshahr Razi Hospital (74%) and Sari Imam Khomeini Hospital (68%) had the highest rates of medical records in EMS.

According to this study, documentation of EMS records was poor. So, recording data should be monitored on a regular basis in all hospitals in Iran and training sessions on this issue should be held for physicians as well as admission and nursing staff.

 Medical records can be defined as a document of the patients' treatment process. Complete and accurate information recording in the medical records of poisoned patients can play an important role in their complete clinical coding. This study aims to determine the amount of registered information required for clinical coding in the medical records of poisoned patients admitted to Imam Reza Hospital in Mashhad, Iran.

 This descriptive cross-sectional study was conducted in 2019. 387 records were selected and reviewed by simple random sampling from all medical records of patients admitted to the poisoning ward of Imam Reza Hospital of Mashhad University of Medical Sciences. The instrument was a valid and reliable checklist. Data analysis was conducted using descriptive statistics.

 The type of poisoning was registered in 387 (100%) medical records and in only 20 (5.2%) medical records the poisoning substance was an unknown drug. In 183 (47.3%) medical records, an external cause was registered for the poisoning, with 19 (4.9%) and 1 (0.3%) medical records including the individual's place of exposure and activity during exposure, respectively.

 The findings of this study can be used to plan and compile the necessary guidelines for the proper accurate documentation of medical records and the possibility of high quality clinical coding.

Experience is obtained as one of the most valuable human assets in different situations and conditions and helps organizations to achieve their strategic goals. The present study was conducted at the Baqiyatallah University of Medical Sciences with aim of designing and compiling a comprehensive empirical program in confronting the COVID-19 crisis.

This applied research was conducted in qualitative and quantitative methods. The statistical population included 24 university experts, managers and executive experts at Baqiyatallah University of Medical Sciences in April and May 2020. All of these individuals were involved in coping with Covid-19. By holding various meetings with the researchers, and obtaining the opinions of experts with the Delphi technique; the events of the crisis and their main axes in dealing with Covid-19 were counted.

Findings show 5 areas and 25 main axes of the event (crisis with domestic, regional, international sensitivity and major damage); 18 events in the field of command and leadership, 15 events in research, 9 events in training, 22 events in healthcare, 6 events in support in dealing with Covid-19. Healthcare is the most common (22) and spirituality is the lowest (2) frequency.

Due to the Covid-19 crisis, healthcare is the most important axis (22 events) and it is necessary to record experience and document for using in similar crises. This empiricism can be used as a basis for managerschr('39') planning to implement experience documentation in the organization.

The present study examines the status of documenting the death certificate in the intensive care unit of the selected hospitals of Mashhad University of Medical Sciences.

This applied research was conducted by combining quantitative and qualitative methods in four stages. At first, the death certificate checklist was created by reviewing the relevant literature and its validity and reliability were assessed. The death certificates issued in the surgical intensive care unit of selected hospitals were then examined. In the third phase, Focus Group documentarians were asked to document the causes of the defect during the focus group sessions. Finally, the results of the steps of the findings were presented to a panel of experts to find the most appropriate solutions.

15 related articles were reviewed out of 76 recovered articles (19.7%). After reviewing the above texts, 4 general areas were identified. The mean score of the direct cause error was 49 and the underlying cause error was 40.5. The reasons for the error were the ambiguity of the physicians in the 19 cases of referral, low motivation, and low awareness of the necessity and manner of completing the death certificate. Strategies for evaluating and responding to documentarians were to formulate general and specific guidelines for completing death certificates for different departments based on the frequency of absurd diagnoses in the workshop.

Applying the strategies of this study can lead to a reduction in ineffective referral to forensic medicine, more accurate completion of the death certificate in hospital.