The investigation of the degree of completion of medical records in the general hospitals of Shiraz University of Medical Sciences
Introduction: Completing medical records plays an important role in educational research and health planning and decision making. Materials and methods: Through systematic sampling of the medical documents of the patients who were discharged from inpatient wards of two general hospitals in the first...
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| Format: | Article |
| Language: | fas |
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Vesnu Publications
2007-10-01
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| Series: | مدیریت اطلاعات سلامت |
| Online Access: | http://him.mui.ac.ir/index.php/him/article/view/7 |
| _version_ | 1818207053904084992 |
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| author | Forouzandeh Ahmadzadeh |
| author_facet | Forouzandeh Ahmadzadeh |
| author_sort | Forouzandeh Ahmadzadeh |
| collection | DOAJ |
| description | Introduction: Completing medical records plays an important role in educational research and health planning and decision making. Materials and methods: Through systematic sampling of the medical documents of the patients who were discharged from inpatient wards of two general hospitals in the first half of 1377. 370 medical documents were selected and examined. The data were collected by seven checklists and descriptive statistics were used to analyze the data. Results: Investigation of the medical records in Namazi and Faghihi hospitals revealed that family history recording was poor, social history and neurological examination recordings were moderate and recording of other pieces of information was optimal. The form of doctor’s orders was completely filled in and the initial diagnosis was optimally recorded. Conclusion: In general, it can be concluded that medical records in general hospitals are optimally completed. However, in order to enhance the quality of completion, it is suggested that the received records to the medical records wards be closely examined by the medical staff and the medical records manager should have direct supervision on the process of completing medical records forms. |
| first_indexed | 2024-12-12T04:22:49Z |
| format | Article |
| id | doaj.art-ce4ca8a067c8441e8cb3b34923bc08eb |
| institution | Directory Open Access Journal |
| issn | 1735-7853 1735-9813 |
| language | fas |
| last_indexed | 2024-12-12T04:22:49Z |
| publishDate | 2007-10-01 |
| publisher | Vesnu Publications |
| record_format | Article |
| series | مدیریت اطلاعات سلامت |
| spelling | doaj.art-ce4ca8a067c8441e8cb3b34923bc08eb2022-12-22T00:38:17ZfasVesnu Publicationsمدیریت اطلاعات سلامت1735-78531735-98132007-10-01117The investigation of the degree of completion of medical records in the general hospitals of Shiraz University of Medical SciencesForouzandeh AhmadzadehIntroduction: Completing medical records plays an important role in educational research and health planning and decision making. Materials and methods: Through systematic sampling of the medical documents of the patients who were discharged from inpatient wards of two general hospitals in the first half of 1377. 370 medical documents were selected and examined. The data were collected by seven checklists and descriptive statistics were used to analyze the data. Results: Investigation of the medical records in Namazi and Faghihi hospitals revealed that family history recording was poor, social history and neurological examination recordings were moderate and recording of other pieces of information was optimal. The form of doctor’s orders was completely filled in and the initial diagnosis was optimally recorded. Conclusion: In general, it can be concluded that medical records in general hospitals are optimally completed. However, in order to enhance the quality of completion, it is suggested that the received records to the medical records wards be closely examined by the medical staff and the medical records manager should have direct supervision on the process of completing medical records forms.http://him.mui.ac.ir/index.php/him/article/view/7 |
| spellingShingle | Forouzandeh Ahmadzadeh The investigation of the degree of completion of medical records in the general hospitals of Shiraz University of Medical Sciences مدیریت اطلاعات سلامت |
| title | The investigation of the degree of completion of medical records in the general hospitals of Shiraz University of Medical Sciences |
| title_full | The investigation of the degree of completion of medical records in the general hospitals of Shiraz University of Medical Sciences |
| title_fullStr | The investigation of the degree of completion of medical records in the general hospitals of Shiraz University of Medical Sciences |
| title_full_unstemmed | The investigation of the degree of completion of medical records in the general hospitals of Shiraz University of Medical Sciences |
| title_short | The investigation of the degree of completion of medical records in the general hospitals of Shiraz University of Medical Sciences |
| title_sort | investigation of the degree of completion of medical records in the general hospitals of shiraz university of medical sciences |
| url | http://him.mui.ac.ir/index.php/him/article/view/7 |
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