Designing and Evaluating a Statistical Management System for Defects of Patients' Medical Records; A Case Study in Iranian Social Security Organization

Information defects in patients' medical records reduce the quality of care services, as well as responsiveness in clinical, legal, and financial cases. This study endeavored to design a system to improve the quality of the management of medical records defects.

In this qualitative study, by observing the activities of users (managers and experts of health information management in selected hospitals of Iranian Social Security Organization) through a system for managing the defects of medical records and conducting semi-structured interviews (n = 10) in year 2021, the performance of designed software (Web PHP with MYSQL Database) was examined. Qualitative data related to activity with software designed by users were classified using content analysis method (MAXQDA).

"Medical Records Defect Management System was defined in two sections of management panel and administrator, each of which had 6 and 7 subsystems, respectively. After developing the software and observing the activity of users while working with the software and interviewing them, the applications of the Medical Records Defect Statistics Management System were classified in the form of 4 main categories of facilities, technological and technical advantages, user friendliness, and training requirements and equipment, as well as 30 subcategories.

The study of the use of Medical Records Defect Management System by medical records users indicates an increase in efficiency and speed in performing activities related to quantitative analysis in medical record, and the possibility of obtaining various reports was satisfactory based on management needs according to defects of medical records in each time period.