The Effect of Filling the Patient Records by Physicians, According to the Instructions, on Incompleteness of Medical Records at Ziaeian Hospital, Tehran, Iran

Document Type : Original Article

Authors
Azam Sadat Hashemi 1
Leila Riahi 2
Leila Nazarimanesh 2
1 MSc, Health Services Management, Department of Health Services Management, School of Sciences and Technology, Science and Research Branch, Islamic Azad University, Tehran, Iran
2 Assistant Professor, Health Services Management, Department of Health Services Management, School of Sciences and Technology, Science and Research Branch, Islamic Azad University, Tehran, Iran
Abstract
Introduction: The full and timely documentation of medical records plays an important role in the improvement of medical, legal, educational, treatment and research processes. Incomplete record keeping is indicative of defective care and treatment. The purpose of this study was to determine the effect of implementation of the instructions on filling the patients' records by physicians on the incompleteness of medical records of Ziaeian Hospital, Tehran, Iran.Methods: This descriptive applied study was carried out at Ziaeian Hospital in 2016. The study population included 2413 medical files filled out in August and December. The sample included 324 incomplete medical files from August (before the implementation) and 288 incomplete medical records in December (after implementation). The medical record checklist was used to collect data. SPSS and Wilcoxon signed-rank tests were employed for data analysis.Results: The mean number of defects was 12.4 and 9.9 before and 9.9 after the intervention, respectively. Number of defects in the admission document (P = 0.012), counseling request (P = 0.048), surgery report (P = 0.001), case summary (P = 0.001) and anesthesia (P = 0.012) showed a significant reduction in the number of defects and the effectiveness of the intervention. However, in total medical record documentation, the intervention was not effective (P = 0.238).Conclusion: It appears that reducing the defects in medical records of Ziaeian Hospital has not been significant which can affect the treatment of patients, the quality of transmission of information and also use of medical records by legal authorities. The results of this research can be useful for hospital directors and managers for a more optimal planning approach.

Keywords

  1. Gozali E, Langarizadeh M, Sadooghi F, Sadeghi M. Electronic medical record, step toward improving the quality of healthcare services and treatment provided to patients. J Ardabil Univ Med Sci 2014; 14(1): 93-6. [In Persian].
  2. DiSantostefano J. Mastering the basics of medical documentation. J Nurse Pract 2007; 3(3): 190-1.
  3. Cox JL, Zitner D, Courtney KD, MacDonald DL, Paterson G, Cochrane B, et al. Undocumented patient information: An impediment to quality of care. Am J Med 2003; 114(3): 211-6.
  4. Skurka MF, Converse ME. Organization of medical record departments in hospitals: Chicago, IL: American Hospital Publishing; 1984.
  5. Hajavi A. Medical record. Tehran, Iran: Iran University of Medical Sciences Publications; 2005. p. 218-55.
  6. Huffman EK. Medical record management. Berwyn, IL: Physicians' Record Company; 1990. p. 100.
  7. Zarei J, Beghlar M, Chettroz A, Goudarzi S, Nikkhah S, Amini M. Document management in the health system styles. Tehran, Iran: Tandis Publications; 2011; p. 9.
  8. Seif Rabiee MA, Sedighi I, Mazdeh M, Dadras F, Shokouhee Solgi M, Moradi A. Study of hospital records registration in teaching hospitals of Hamadan University of Medical Sciences in 2009. Avicenna J Clin Med 2009; 16(2): 45-9. [In Persian].
  9. Sadoughi F, Meidani Z, Farzandipour M, Davoodabadi A, Farrokhian A, Gilasi H. The effect of feedback and incentive mechanisms on improving residents' medical record documentation procedure. Iran J Med Educ 2015; 15: 648-55. [In Persian].
  10. Mehraeen E, Raeissi P, Omid Kohan Shoori Z, Ahmadi P, Jani Iranadgan S, Saravani S. Review of medical records documentation in obstetrics and gynecology ward (data quantitative analysis on obstetrics and gynecology ward). Advances in Nursing & Midwifery 2015; 24(87): 37-44. [In Persian].
  11. Faridaalaee G, Boushehri B, Mohammadi N, Safari O. Evaluating the quality of multiple trauma patient records in the emergency department of Imam Khomeini Hospital in Urmia. Iranian Journal of Emergency Medicine 2015; 2(2): 88-92. [In Persian].
  12. Yunuswangsa Q, Nimmaanrat S, Wasinwong W. Completion and accuracy in charting of anesthetic records in Songklanagarind Hospital. J Med Assoc Thai 2008; 91(7): 1002-10.
  13. Parsa Mahjob M, Farahabadi M, Dalir M. Medical record department problems (admission unit, filling unit, coding unit, statistical unit) in Motahari & Peymani hospitals in 2008. J Jahrom Univ Med Sci 2010; 8(1): 47-51. [In Persian].
  14. Rooney AL, van Ostenberg PR. Licensure, accreditation, and certification: Approaches to health services quality [Online]. [cited 2009]; Available from: URL: https://www.usaidassist.org/resources/licensure-accreditation-and-certification-approaches-health-services-quality-0
  15. Farzadipour M, Asefzadeh S. Surveying the principle of diagnosis recording in patients' medical records of Kashan hospitals in 2002. Feyz 2004; 8(3): 36-44. [In Persian].
  16. Ariyaei M. A survey on the contents of medical records general hospitals affiliated with Kerman University of Medical Sciences during the first three months of 1998. J Health Adm 2002; 4(11): 65-70. [In Persian].
  17. Abbasi S, Tavakoli N, Quantitative analysis of medical record of patients admitted in the Gharazi hospital. Health Inf Manage; 2011; 8(1): 50-60. [In Persian].
  18. Farough-Khosravi M, Salimlar S, Rostamzadeh A, Shadkam N, Doshmangir L. The relationship between folic acid intake and infant birth weight, Depiction of Health 2016; 7(3): 38-45. [In Persian].
  19. Nasseri K, Farsian SE. Assessing anesthetic indexes in patient's medical records. Health Inf Manage 2014; 11(3): 285-92. [In Persian].
  20. Afzali S, Seyferabiei MA, Naghdi S. Processing of file record for multiple traumatic patients in Hamedan's Besat Hospital in 2008. Sci J Forensic Med 2011; 17(2): 79-86. [In Persian].
  21. Esmailian M, Nasr-Esfahani M, Brahimi AS. The quality of patients' files documentation in emergency department; A cross sectional study. Iranian Journal of Emergency Medicine 2014; 1(1): 16-21. [In Persian].
Health Information Management
Volume 14, Issue 5 - Serial Number 5
Autumn 2017
Pages 194-198