Evaluating Documentation for Coding of Poisoning Medical Records in Imam Reza Hospital, Mashhad, Iran
Introduction: 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 registe...
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| Format: | Article |
| Language: | fas |
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Vesnu Publications
2020-07-01
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| Series: | مدیریت اطلاعات سلامت |
| Subjects: | |
| Online Access: | http://him.mui.ac.ir/index.php/him/article/view/4088 |
| _version_ | 1819292678498549760 |
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| author | Alireza Banaye-Yazdipour Masoumeh Sarbaz Bita Dadpour Atieh Malekinejad Khalil Kimiafar |
| author_facet | Alireza Banaye-Yazdipour Masoumeh Sarbaz Bita Dadpour Atieh Malekinejad Khalil Kimiafar |
| author_sort | Alireza Banaye-Yazdipour |
| collection | DOAJ |
| description | Introduction: 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.
Methods: 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.
Results: 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.
Conclusion: 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. |
| first_indexed | 2024-12-24T03:58:21Z |
| format | Article |
| id | doaj.art-b35f1595ba8d423aa411abe73f9ba1fb |
| institution | Directory Open Access Journal |
| issn | 1735-7853 1735-9813 |
| language | fas |
| last_indexed | 2024-12-24T03:58:21Z |
| publishDate | 2020-07-01 |
| publisher | Vesnu Publications |
| record_format | Article |
| series | مدیریت اطلاعات سلامت |
| spelling | doaj.art-b35f1595ba8d423aa411abe73f9ba1fb2022-12-21T17:16:23ZfasVesnu Publicationsمدیریت اطلاعات سلامت1735-78531735-98132020-07-01173909610.22122/him.v17i3.40881074Evaluating Documentation for Coding of Poisoning Medical Records in Imam Reza Hospital, Mashhad, IranAlireza Banaye-Yazdipour0Masoumeh Sarbaz1Bita Dadpour2Atieh Malekinejad3Khalil Kimiafar4MSc Student, Health Information Technology, Department of Medical Records and Health Information Technology, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran Student Research Committee, Mashhad University of Medical Sciences, Mashhad, IranAssistant Professor, Medical Informatics, Department of Medical Records and Health Information Technology, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, IranAssociate Professor, Internist and Clinical Toxicology Fellowship, Medical Toxicology Research Center, Mashhad University of Medical Sciences, Mashhad, IranBSc, Health Information Technology, Department of Medical Records and Health Information Technology, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, IranAssistant Professor, Health Information Management, Department of Medical Records and Health Information Technology, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, IranIntroduction: 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. Methods: 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. Results: 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. Conclusion: 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.http://him.mui.ac.ir/index.php/him/article/view/4088poisoningmedical recordsclinical codingdocumentationinternational classification of diseases |
| spellingShingle | Alireza Banaye-Yazdipour Masoumeh Sarbaz Bita Dadpour Atieh Malekinejad Khalil Kimiafar Evaluating Documentation for Coding of Poisoning Medical Records in Imam Reza Hospital, Mashhad, Iran مدیریت اطلاعات سلامت poisoning medical records clinical coding documentation international classification of diseases |
| title | Evaluating Documentation for Coding of Poisoning Medical Records in Imam Reza Hospital, Mashhad, Iran |
| title_full | Evaluating Documentation for Coding of Poisoning Medical Records in Imam Reza Hospital, Mashhad, Iran |
| title_fullStr | Evaluating Documentation for Coding of Poisoning Medical Records in Imam Reza Hospital, Mashhad, Iran |
| title_full_unstemmed | Evaluating Documentation for Coding of Poisoning Medical Records in Imam Reza Hospital, Mashhad, Iran |
| title_short | Evaluating Documentation for Coding of Poisoning Medical Records in Imam Reza Hospital, Mashhad, Iran |
| title_sort | evaluating documentation for coding of poisoning medical records in imam reza hospital mashhad iran |
| topic | poisoning medical records clinical coding documentation international classification of diseases |
| url | http://him.mui.ac.ir/index.php/him/article/view/4088 |
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