Document Type : Original Article(s)
Author
Abstract
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.
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