Document Type : Original Article(s)
Author
Abstract
Introduction: Medical information is a major tool in planning, coordinating and evaluating the delivered healthcare. In addition, documentation of medical records is useful for legal, educational and research purposes, managerial planning and accreditation. The purpose of this study is to identify the reasons for incompleteness of medical records and the physicians and managers' views in this regard. Methods and Materials: It is a cross-sectional study in which 71 managers and 69 physicians participated . The data were collected by a questionnaire which consisted of two parts: the reasons for incompleteness of medical reconds and the participants' suggestions to eliminate this problem. Results : The main reason for incompleteness of medical records was that the medical staff were not trained adequately to fill in the medical records (53% managers, 55% physicians). 52% of the participants also believed that attendents do not monitor regularly the interns and residents' performance in filling in medical documents. Conclusion : It was proposed to hold training courses for the medical staff regarding how to fill in the medical records completely and accurately. Key words: medical records – hospital administrators – nurse administrators – hospitals – hospitals, university - physicians
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