The Rate of Adherence to Principles of Diagnosis Recording in Medical Records of Patients with Fractures Admitted to Urmia Motahari Hospital
Introduction: A patient's medical record is the most important source for medical research, education and law. The physician's role, as the head of the medical team, in registration of accurate information of diagnoses, orders and observations is of utmost importance. This research aimed t...
| Main Authors: | , , , |
|---|---|
| Format: | Article |
| Language: | fas |
| Published: |
Vesnu Publications
2011-08-01
|
| Series: | مدیریت اطلاعات سلامت |
| Online Access: | http://him.mui.ac.ir/index.php/him/article/view/298 |
| _version_ | 1818790479721922560 |
|---|---|
| author | Zahra Zare Fazlollahi Masoomeh Khoshkalam Aghdam Hadi Lotfnezhad Afshar Mohammad Jabraili |
| author_facet | Zahra Zare Fazlollahi Masoomeh Khoshkalam Aghdam Hadi Lotfnezhad Afshar Mohammad Jabraili |
| author_sort | Zahra Zare Fazlollahi |
| collection | DOAJ |
| description | Introduction: A patient's medical record is the most important source for medical research, education and law. The physician's role, as the head of the medical team, in registration of accurate information of diagnoses, orders and observations is of utmost importance. This research aimed to determine the rate of adherence to principles of diagnosis recording in medical records of patients with fractures hospitalized at Urmia Motahari Hospital.
Methods: This cross-sectional survey was conducted on the records of patients admitted to Urmia Motahari Hospital with a final diagnosis of fracture in 2007. A sample size of 400 records was selected randomly. A checklist was used to determine whether or not the necessary information was recorded. The checklist, the validity and reliability of which have been confirmed, included anatomic site, type, shape (closed or open), external cause and fracture-related injuries. The results were shown as frequency tables.
Results: Based on our results, the most recorded item was the site of fracture (97.25%) and the lowest was the shape of fracture (7%). None of records included all items. In addition, only 1.25% of the records contained 4 items.
Conclusion: Incomplete recording of final diagnosis in the patient's record is one of the main problems of documentation. Chart writing is one of the most important responsibilities of physicians and medical teams, which, according to our results, is not taken seriously. Chart writing can be improved by workshops. Establishment of rules for documentation can also increase the adherence to principles of documentation.
Keywords: Documentation; Medical Records; Inpatient; Fracture; Bone. |
| first_indexed | 2024-12-18T14:56:07Z |
| format | Article |
| id | doaj.art-838a23394a0c4e189b6829e5d74dec75 |
| institution | Directory Open Access Journal |
| issn | 1735-7853 1735-9813 |
| language | fas |
| last_indexed | 2024-12-18T14:56:07Z |
| publishDate | 2011-08-01 |
| publisher | Vesnu Publications |
| record_format | Article |
| series | مدیریت اطلاعات سلامت |
| spelling | doaj.art-838a23394a0c4e189b6829e5d74dec752022-12-21T21:04:02ZfasVesnu Publicationsمدیریت اطلاعات سلامت1735-78531735-98132011-08-0183240The Rate of Adherence to Principles of Diagnosis Recording in Medical Records of Patients with Fractures Admitted to Urmia Motahari HospitalZahra Zare Fazlollahi0Masoomeh Khoshkalam Aghdam1Hadi Lotfnezhad Afshar2Mohammad Jabraili3Lecturer, Health Information Technology, Urmia University of Medical Sciences, Urmia, Iran.Lecturer, Department of Health Information Technology, Urmia University of Medical Sciences, Urmia, Iran.Lecturer, Health Information Technology, Urmia University of Medical Sciences, Urmia, Iran.Lecturer, Department of Health Information Technology, Urmia University of Medical Sciences, Urmia, Iran.Introduction: A patient's medical record is the most important source for medical research, education and law. The physician's role, as the head of the medical team, in registration of accurate information of diagnoses, orders and observations is of utmost importance. This research aimed to determine the rate of adherence to principles of diagnosis recording in medical records of patients with fractures hospitalized at Urmia Motahari Hospital. Methods: This cross-sectional survey was conducted on the records of patients admitted to Urmia Motahari Hospital with a final diagnosis of fracture in 2007. A sample size of 400 records was selected randomly. A checklist was used to determine whether or not the necessary information was recorded. The checklist, the validity and reliability of which have been confirmed, included anatomic site, type, shape (closed or open), external cause and fracture-related injuries. The results were shown as frequency tables. Results: Based on our results, the most recorded item was the site of fracture (97.25%) and the lowest was the shape of fracture (7%). None of records included all items. In addition, only 1.25% of the records contained 4 items. Conclusion: Incomplete recording of final diagnosis in the patient's record is one of the main problems of documentation. Chart writing is one of the most important responsibilities of physicians and medical teams, which, according to our results, is not taken seriously. Chart writing can be improved by workshops. Establishment of rules for documentation can also increase the adherence to principles of documentation. Keywords: Documentation; Medical Records; Inpatient; Fracture; Bone.http://him.mui.ac.ir/index.php/him/article/view/298 |
| spellingShingle | Zahra Zare Fazlollahi Masoomeh Khoshkalam Aghdam Hadi Lotfnezhad Afshar Mohammad Jabraili The Rate of Adherence to Principles of Diagnosis Recording in Medical Records of Patients with Fractures Admitted to Urmia Motahari Hospital مدیریت اطلاعات سلامت |
| title | The Rate of Adherence to Principles of Diagnosis Recording in Medical Records of Patients with Fractures Admitted to Urmia Motahari Hospital |
| title_full | The Rate of Adherence to Principles of Diagnosis Recording in Medical Records of Patients with Fractures Admitted to Urmia Motahari Hospital |
| title_fullStr | The Rate of Adherence to Principles of Diagnosis Recording in Medical Records of Patients with Fractures Admitted to Urmia Motahari Hospital |
| title_full_unstemmed | The Rate of Adherence to Principles of Diagnosis Recording in Medical Records of Patients with Fractures Admitted to Urmia Motahari Hospital |
| title_short | The Rate of Adherence to Principles of Diagnosis Recording in Medical Records of Patients with Fractures Admitted to Urmia Motahari Hospital |
| title_sort | rate of adherence to principles of diagnosis recording in medical records of patients with fractures admitted to urmia motahari hospital |
| url | http://him.mui.ac.ir/index.php/him/article/view/298 |
| work_keys_str_mv | AT zahrazarefazlollahi therateofadherencetoprinciplesofdiagnosisrecordinginmedicalrecordsofpatientswithfracturesadmittedtourmiamotaharihospital AT masoomehkhoshkalamaghdam therateofadherencetoprinciplesofdiagnosisrecordinginmedicalrecordsofpatientswithfracturesadmittedtourmiamotaharihospital AT hadilotfnezhadafshar therateofadherencetoprinciplesofdiagnosisrecordinginmedicalrecordsofpatientswithfracturesadmittedtourmiamotaharihospital AT mohammadjabraili therateofadherencetoprinciplesofdiagnosisrecordinginmedicalrecordsofpatientswithfracturesadmittedtourmiamotaharihospital AT zahrazarefazlollahi rateofadherencetoprinciplesofdiagnosisrecordinginmedicalrecordsofpatientswithfracturesadmittedtourmiamotaharihospital AT masoomehkhoshkalamaghdam rateofadherencetoprinciplesofdiagnosisrecordinginmedicalrecordsofpatientswithfracturesadmittedtourmiamotaharihospital AT hadilotfnezhadafshar rateofadherencetoprinciplesofdiagnosisrecordinginmedicalrecordsofpatientswithfracturesadmittedtourmiamotaharihospital AT mohammadjabraili rateofadherencetoprinciplesofdiagnosisrecordinginmedicalrecordsofpatientswithfracturesadmittedtourmiamotaharihospital |