Mohammad Reza Esmaeili Dooki; Hadi Sorkhi; Seyed Abbas Fatemi; Fatemeh Hosseinzadeh; Yadollah Zahedpasha; Ahmad Tamaddoni; Naeimeh Nakhjavani; Rahim Barari Savadkohi; Iraj Mohammadzadeh; Mohammad Reza Salehiomran; Mousa Ahmadpour Kacho; Abbas Hadipoor; Soheil Osia; Mahmoud Hajiahmadi; Ali Bijani; Hassan Mahmoodi Nesheli; Peiman Eshraghi; Kazem Babazadeh; Ali Mohammadpour Mir
Volume 9, Issue 3 , May and June 2012
Abstract
Introduction: Medical records consist of documents evidencing a patient's health status at a moment of life. There is a close relationship between disease progress and daily physician orders issued in medical records. Each order in fact reflects the patient's medical status and his/her disease progress. ...
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Introduction: Medical records consist of documents evidencing a patient's health status at a moment of life. There is a close relationship between disease progress and daily physician orders issued in medical records. Each order in fact reflects the patient's medical status and his/her disease progress. In this study, while keeping the previous progress page in the records, a column of brief disease progress was included in physician order sheets to increase the quality of records and promote the education of learners.Methods: In this cross-sectional controlled interventional study, medical records of all patients admitted to super specialty wards of Amirkola Children Hospital during the first quarters of 2009 and 2010 were included. From a total of 3462 records, 150 records were studied each year. Each indicator of disease progress, which was recorded based on subjective, objective, assessment, and plan (SOAP) note, was given a score. Finally, if only three indicators were mentioned in the record, it was considered as poor. Scores 4-5 represented moderate and scores 6-7 were considered as good. The scores of the records were then compared using statistical tests including t-test, paired t-test, Pearson's correlation coefficient, chi-square test, Fisher's exact test, and Kappa coefficient. P values less than 0.05 were considered as significant.Results: The mean number of physician orders in records during the first quarters of 2009 and 2010 were respectively 9.15 ± 10.8 and 8.45 ± 6.80 cases. Good scores had the highest frequency in the new brief disease progress form. The highest average of results in the studied groups was observed in brief disease progress notes of 2010. Comparison of mean scores revealed statistically significant differences (P < 0.05).Conclusion: Adding a new column named "brief disease progressive note" in physician order sheets significantly promoted the recording of disease progress and reasons for medical orders based on SOAP note. Therefore, it is recommended to include this column in physician order sheets.Keywords: Medical Records; Progressive Note; Physician Order Sheet; Documentation.
