Quality of Patients' Files Documenting by Medical Students and Physicians at Tohid Hospital in Sanandaj

Numerous studies conducted in Iran have shown that the quality of documentation of medical records by physicians and medical staff is not very satisfactory. The purpose of this study was to investigate the quality of medical records documentation in a teaching hospital, Tohid, in Sanandaj, Iran.

In a descriptive-analytical study, the medical records of all patients admitted to various services of Tohid Hospital in Sanandaj in the first six months of 2017 were examined. The investigated variables were collected using a checklist based on the national regulations for the documentation of medical records prepared by the Ministry of Health and Medical Education (Deputy of Treatment). Data were analyzed using SPSS V.20 software and Chi-squared test.

In the present study, the correct diagnosis registration, in accordance with the principles of diagnosis, was observed in 61% of admission forms and the first visit of the physician was recorded in 66% of cases. Compared with the standard, 84% of patients had a visit to a specialist within half an hour of being admitted to the hospital. More than half of the history sheets and most of the initial, daily, and final reports were incomplete. The percentage of evaluation of professors from the history sheets of residents, interns and externs was 41%, 22% and 10%, respectively. About 66 percent of the doctorchr(chr('39')39chr('39'))s prescriptions were properly recorded in the files. The correct registration of medical orders in interns and residents was 69% and 88%, respectively. Medical orders recorded by professors were recorded in 54% of cases without defects. The lowest number of defects was observed in the professors of neurology and emergency medicine and the most cases of defects were observed in the service of the professors of the cardiology. Failure to record the time and date was observed in 80% and 14% of the medical orders, respectively. Emergency medicine records differed significantly from other cases in that they had the correct diagnosis in accordance with the principles of diagnosis, and emergency medicine professors had more control over the recording of information in various forms of each case.

Based on the findings of this study, it is necessary to hold training courses on proper documentation of medical records for physicians and learners in this field and more precise supervision of professors and physicians treating studentschr(chr('39')39chr('39')) performance in all educational hospitals of Kurdistan University of Medical Sciences.